Information Collection

Baseline Survey

IC 273472 under ICR 202501-0703-001 · OMB unassigned.

Documents and Forms

Document Name Document Type
SDOH BL 19DEC2024.pdf Other-Survey
SDoH Baseline Questionnaire 04FEB2025.pdf Other-Survey

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Baseline Survey	Agency IC Tracking Number:

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
Other-Survey			SDoH Baseline Questionnaire 04FEB2025.pdf		Yes	Yes	Fillable Fileable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,088	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,088	1,088
Annual IC Time Burden (Hours)	272	272
Annual IC Cost Burden (Dollars)	4,132	4,132

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.