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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

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.