Information Collection

Baseline survey

IC 271895 under ICR 202412-0920-003 · OMB 0920-1446.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1446 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-25AU Baseline survey	Form and Instruction
Form 0920-25AU INITIAL CLINCAL AND SOCIAL SURVEY Baseline survey	Form and Instruction
Form 0920-1446 INITIAL CLINCAL AND SOCIAL SURVEY_04DEC2024 Baseline survey	Form and Instruction
0920-25AU INITIAL CLINCAL AND SOCIAL SURVEY Att. 3 Initial Clinical and Social Survey_Revised.docx	Form and Instruction
0920-25AU INITIAL CLINCAL AND SOCIAL SURVEY Att. 3 Initial Clinical and Social Survey_Revised.docx	Form and Instruction
0920-1446 INITIAL CLINCAL AND SOCIAL SURVEY_04DEC2024 Att. 3 Initial Clinical and Social Survey_Clean_29Nov2024.docx	Form and Instruction
0920-1446 INITIAL CLINCAL AND SOCIAL SURVEY_04DEC2024 Att. 3 Initial Clinical and Social Survey_Clean_29Nov2024.docx	Form and Instruction

IC Title:

Baseline survey

Agency IC Tracking Number:

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	0920-25AU				Yes	Yes	Fillable Fileable
Form and Instruction	0920-1446			N/A	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 200

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	Previously Approved
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	100	100
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.

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