Early Exit Interview

Evaluation of Public Health AmeriCorps

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3045-0199 can be found here:

Documents and Forms

Document Name Document Type
05-Early Exit Interview.docx Other-Interview Questions
05-Early Exit Interview.docx Other-Interview Questions

Information Collection (IC) Details

IC Title:	Early Exit Interview	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-Interview Questions			05-Early Exit Interview.docx		No		Printable Only

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	10	10
Annual IC Time Burden (Hours)	5	5
Annual IC Cost Burden (Dollars)	237	237

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.