Background and Demographic Information Form

National Healthy Start Evaluation and Quality Assurance

Documents and Forms

Document Name Document Type
Form 2 Background and Demographic Information Form Form and Instruction
Form 2 Background and Demographic Information Form Form and Instruction
2 Background Form B1 - Background Form.docx Form and Instruction
2 Background Form B1 - Background Form.docx Form and Instruction
1 Demographic Form Attachment 1 - Demographic_Form.docx Form and Instruction
1 Demographic Form Attachment 1 - Demographic_Form.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Background and Demographic Information Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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
Form and Instruction	2	Background Form	B1 - Background Form.docx		Yes	Yes	Fillable Fileable
Form and Instruction	1	Demographic Form	Attachment 1 - Demographic_Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 45,450	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 75 %

	Approved	Previously Approved
Annual Number of Responses for this IC	45,450	45,450
Annual IC Time Burden (Hours)	27,270	27,270
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.