Head Of Household Waitlist Family Informed Consent For Study Participation

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⚠️ Notice: This information collection may be referencing outdated material.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
Revised - Attachment C Head of Household Waitlist Family Informed Consent.docx Other-Revised - Attachment C Head of
Revised - Attachment C Head of Household Waitlist Family Informed Consent.docx Other-Revised - Attachment C Head of
Revised - Attachment C Head of Household Waitlist Family Informed Consent - CLEAN.docx Other- Revised - Attachment C Head o
Revised - Attachment C Head of Household Waitlist Family Informed Consent - CLEAN.docx Other- Revised - Attachment C Head o

Information Collection (IC) Details

IC Title:	HEAD OF HOUSEHOLD WAITLIST FAMILY INFORMED CONSENT FOR STUDY PARTICIPATION	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-Revised - Attachment C Head of Household Waitlist Family Informed Consent			Revised - Attachment C Head of Household Waitlist Family Informed Consent.docx		Yes	Yes	Fillable Fileable
Other- Revised - Attachment C Head of Household Waitlist Family Informed Consent			Revised - Attachment C Head of Household Waitlist Family Informed Consent - CLEAN.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: 3,166	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	3,166	3,166
Annual IC Time Burden (Hours)	792	792
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.