Information Collection

Grantee Baseline Survey

IC 260414 under ICR 202505-0915-001 · OMB 0915-0392.

Documents and Forms

Document Name Document Type
Form 1 Grantee Baseline Survey Form
Form 1 Grantee Baseline Survey Grantee Baseline Survey Form
1 Grantee Baseline Survey Attachment2_RPHWTNPGranteeBaselineSurvey.pdf Form
1 Grantee Baseline Survey Attachment2_RPHWTNPGranteeBaselineSurvey.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Grantee Baseline Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	Grantee Baseline Survey	Attachment2_RPHWTNPGranteeBaselineSurvey.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 32	Number of Respondents for Small Entity: 20

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	32	32
Annual IC Time Burden (Hours)	8	8
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.

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