Information Collection

Baseline Questionnaire

IC 271429 under ICR 202410-0920-008 · OMB 0920-1449.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1449 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-24AL Baseline Questionnaire Form
0920-24AL Baseline Questionnaire Att. 7–Baseline Questionnaire.docx Form
0920-24AL Baseline Questionnaire Att. 7–Baseline Questionnaire.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Baseline Questionnaire	Agency IC Tracking Number:	0920-24AL

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
Form	0920-24AL	Baseline Questionnaire	Att. 7âBaseline Questionnaire.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	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	50	50
Annual IC Time Burden (Hours)	24	24
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.