Information Collection

Baseline Information Form (household survey)

IC 254350 under ICR 202204-2528-001 · OMB 2528-0339.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2528-0339 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Final - Attachment A STRD Baseline Information Form.docx	Other-Baseline Information Form (hou
Final - Attachment A STRD Baseline Information Form.docx	Other-Baseline Information Form (hou

IC Title:

Baseline Information Form (household survey)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Baseline Information Form (household survey)			Final - Attachment A STRD Baseline Information Form.docx		No		Paper Only

Line of Business: Community and Social Services

Subfunction: Community and Regional Development

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 24,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	24,000	24,000
Annual IC Time Burden (Hours)	2,880	2,880
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.