Information Collection

Assessment Evaluation - Individual or Household Respondents

IC 185868 under ICR 202403-3320-002 · OMB 3320-0003.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3320-0003 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3320-0003 (A) Assessment Evaluation - Individual or Household Respondents	Form and Instruction
3320-0003 (A) Assessment Evaluation Assessment Evaluation - Requester Questionnaire - 0003A.pdf	Form and Instruction
3320-0003 (A) Assessment Evaluation Assessment Evaluation - Requester Questionnaire - 0003A.pdf	Form and Instruction

IC Title:

Assessment Evaluation - Individual or Household Respondents

Agency IC Tracking Number:

0003A

Is this a Common Form? No

IC Status: Modified

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
Form and Instruction	3320-0003 (A)	Assessment Evaluation	Assessment Evaluation - Requester Questionnaire - 0003A.pdf		Yes	Yes	Fillable Fileable

Line of Business: Litigation and Judicial Activities

Subfunction: Resolution Facilitation

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: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	10	-65	75
Annual IC Time Burden (Hours)	1	-5	6
Annual IC Cost Burden (Dollars)	53	53	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.