Information Collection

Tailored Services Practice Model Survey

IC 226791 under ICR 202306-0970-013 · OMB 0970-0501.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
TAB H_Tailored Services Practice Model Survey.docx	Other-Model Survey
TAB H_Tailored Services Practice Model Survey.docx	Other-Model Survey

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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-Model Survey			TAB H_Tailored Services Practice Model Survey.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: 130

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-130	130
Annual IC Time Burden (Hours)	-16	16
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.