Information Collection

Baseline information form for participants (Attachments D)

IC 235592 under ICR 202209-0970-015 · OMB 0970-0537.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0537 can be found here:

Documents and Forms

Document Name Document Type
BEES_NonSub Change Request_Attachment D-Generic BIF CLEAN_Nov-Dec 2020.docx Other-Standard BIF
BEES_NonSub Change Request_Attachment D-Generic BIF CLEAN_Nov-Dec 2020.docx Other-Standard BIF
Attachment D-1_BEES_BIF ARC_Clean.docx Other-Tailored BIF - ARC Site
Attachment D-1_BEES_BIF ARC_Clean.docx Other-Tailored BIF - ARC Site
Attachment D-2_BEES_BIF CCC_Clean.docx Other-Tailored BIF - CCC Site
Attachment D-2_BEES_BIF CCC_Clean.docx Other-Tailored BIF - CCC Site
Attachment D-3_BEES_BIF Franklin-Stark_Clean.docx Other-Tailored BIF - Franklin-Stark
Attachment D-3_BEES_BIF Franklin-Stark_Clean.docx Other-Tailored BIF - Franklin-Stark
Attachment D-4_BEES_BIF 2Gen-Chicago_Clean.docx Other-Tailored BIF - 2Gen-Chicago Si
Attachment D-4_BEES_BIF 2Gen-Chicago_Clean.docx Other-Tailored BIF - 2Gen-Chicago Si
Attachment D-5_BEES_BIF IPS FQHC_Clean.docx Other-Tailored BIF - IPS FQHC site
Attachment D-5_BEES_BIF IPS FQHC_Clean.docx Other-Tailored BIF - IPS FQHC site
Attachment D-1_BEES_IPS SUD BIF_May 2021_Clean.docx Other-Tailored BIF - IPS SUD
Attachment D-1_BEES_IPS SUD BIF_May 2021_Clean.docx Other-Tailored BIF - IPS SUD
BEES_NonSub Change Request_Attachment D-BIF-TANF-SNAP study.docx Other-Tailored BIF - TANF-SNAP study
BEES_NonSub Change Request_Attachment D-BIF-TANF-SNAP study.docx Other-Tailored BIF - TANF-SNAP study

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Baseline information form for participants (Attachments D)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Standard BIF	BEES_NonSub Change Request_Attachment D-Generic BIF CLEAN_Nov-Dec 2020.docx	Yes	Yes	Fillable Fileable
Other-Tailored BIF - ARC Site	Attachment D-1_BEES_BIF ARC_Clean.docx	Yes	Yes	Fillable Fileable
Other-Tailored BIF - CCC Site	Attachment D-2_BEES_BIF CCC_Clean.docx	Yes	Yes	Fillable Fileable
Other-Tailored BIF - Franklin-Stark Site	Attachment D-3_BEES_BIF Franklin-Stark_Clean.docx	Yes	Yes	Fillable Fileable
Other-Tailored BIF - 2Gen-Chicago Site	Attachment D-4_BEES_BIF 2Gen-Chicago_Clean.docx	Yes	Yes	Fillable Fileable
Other-Tailored BIF - IPS FQHC site	Attachment D-5_BEES_BIF IPS FQHC_Clean.docx	Yes	Yes	Fillable Fileable
Other-Tailored BIF - IPS SUD	Attachment D-1_BEES_IPS SUD BIF_May 2021_Clean.docx	Yes	Yes	Fillable Fileable
Other-Tailored BIF - TANF-SNAP study	BEES_NonSub Change Request_Attachment D-BIF-TANF-SNAP study.docx	Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,000	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	Previously Approved
Annual Number of Responses for this IC	1,000	-3,133	4,133
Annual IC Time Burden (Hours)	250	-784	1,034
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.