Information Collection

Client Intake Form (data manager)

IC 260396 under ICR 202305-0920-002 · OMB 0920-1410.

Documents and Forms

Document Name Document Type
Client Intake Form (data manager) Form and Instruction
TRANSCEND Intake Form Att3a_IntakeForm.docx Form and Instruction
TRANSCEND Intake Form Att3a_IntakeForm.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Client Intake Form (data manager)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	None	TRANSCEND Intake Form	Att3a_IntakeForm.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	8	8
Annual IC Time Burden (Hours)	16	16
Annual IC Cost Burden (Dollars)	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.