Baseline Information Form

The Evaluation of the Pathway Home Grant Program (Pathway Home Evaluation)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1290-0039 can be found here:

Documents and Forms

Document Name Document Type
PHE QED Baseline Information Form_June2022_clean (1).docx Other-Information form
PHE QED Baseline Information Form_June2022_clean (1).docx Other-Information form
PHE QED Participant Consent Form_June2022_clean.docx Participant consent form IC Document
PHE QED Participant Consent Form_June2022_clean.docx Participant consent form IC Document

Information Collection (IC) Details

IC Title:	Baseline Information Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Information form			PHE QED Baseline Information Form_June2022_clean (1).docx		Yes	Yes	Fillable Fileable

Line of Business: Workforce Management

Subfunction: Training and Employment

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 833	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	833	833
Annual IC Time Burden (Hours)	208	208
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Participant consent form	PHE QED Participant Consent Form_June2022_clean.docx	08/29/2022

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