Adult Survey

The Community Choice Demonstration

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2528-0337 can be found here:

Documents and Forms

Document Name Document Type
Final - Attachment M.1_The Obesity & Type II Diabetes Risk Asessment_Survey_Baseline.docx Other-Adult Survey
Attachment M.1_The Obesity Type II Diabetes Risk Assessment_Survey_Baseline.docx Other-Adult Survey
Final - Attachment M.2_The Obesity & Type II Diabetes Risk Assessment_Survey_Follow_up.docx Other-Adult Survey
Attachment M.2_The Obesity Type II Diabetes Risk Assessment_Survey_Follow-up.docx Other-Adult Survey

Information Collection (IC) Details

IC Title:	Adult Survey	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-Adult Survey			Attachment M.1_The Obesity Type II Diabetes Risk Assessment_Survey_Baseline.docx		Yes	Yes	Fillable Fileable
Other-Adult Survey			Attachment M.2_The Obesity Type II Diabetes Risk Assessment_Survey_Follow-up.docx		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Community and Regional Development

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 900	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	1,800	1,800
Annual IC Time Burden (Hours)	1,800	1,800
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.