Information Collection

Baseline Information Form

IC 255685 under ICR 202301-1290-001 · OMB 1290-0039.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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 Baseline Information Form_Jan2023_clean_forOMB.docx www.PHEvaluation.org/Enrollment	Other-Information Form
PHE QED Baseline Information Form_Jan2023_clean_forOMB.docx www.PHEvaluation.org/Enrollment	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
PHE QED Baseline Information Form_Jan2023_trcks_forOMB.docx PHE QED Baseline Information Form_Jan2023_trcks_forOMB	IC Document
PHE QED Baseline Information Form_Jan2023_trcks_forOMB.docx PHE QED Baseline Information Form_Jan2023_trcks_forOMB	IC Document
PHE QED Participant Consent Form_Jan2023_Program_clean_forOMB.docx PHE QED Participant Consent Form_Jan2023_Program_clean_forOMB	IC Document
PHE QED Participant Consent Form_Jan2023_Program_clean_forOMB.docx PHE QED Participant Consent Form_Jan2023_Program_clean_forOMB	IC Document
PHE QED Participant Consent Form_Jan2023_Program_trcks_forOMB.docx PHE QED Participant Consent Form_Jan2023_Program_trcks_forOMB	IC Document
PHE QED Participant Consent Form_Jan2023_Program_trcks_forOMB.docx PHE QED Participant Consent Form_Jan2023_Program_trcks_forOMB	IC Document

IC Title:

Baseline Information Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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-Information form			PHE QED Baseline Information Form_June2022_clean (1).docx		Yes	Yes	Fillable Fileable
Other-Information Form			PHE QED Baseline Information Form_Jan2023_clean_forOMB.docx	https://www.PHEvaluation.org/Enrollment	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 %

table that charts list of burden
	Approved	Previously Approved
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

table that charts IC Documents
Title	Document	Date Uploaded
Participant consent form	PHE QED Participant Consent Form_June2022_clean.docx	08/29/2022
PHE QED Baseline Information Form_Jan2023_trcks_forOMB	PHE QED Baseline Information Form_Jan2023_trcks_forOMB.docx	01/30/2023
PHE QED Participant Consent Form_Jan2023_Program_clean_forOMB	PHE QED Participant Consent Form_Jan2023_Program_clean_forOMB.docx	01/30/2023
PHE QED Participant Consent Form_Jan2023_Program_trcks_forOMB	PHE QED Participant Consent Form_Jan2023_Program_trcks_forOMB.docx	01/30/2023

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