Household Roster And Baseline Information Form

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⚠️ Notice: This information collection may be referencing outdated material.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 - Instrument 1 Household Roster and Baseline Information Form_Rev_24August2022.docx Other-Revised - Instrument 1 Househo
Revised - Instrument 1 Household Roster and Baseline Information Form_Rev_24August2022.docx Other-Revised - Instrument 1 Househo

Information Collection (IC) Details

IC Title:	HOUSEHOLD ROSTER AND BASELINE INFORMATION FORM	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 - Instrument 1 Household Roster and Baseline Information Form_Rev_24August2022			Revised - Instrument 1 Household Roster and Baseline Information Form_Rev_24August2022.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: 10,100	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	10,100	10,100
Annual IC Time Burden (Hours)	7,575	7,575
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.