Information Collection

Baseline survey

IC 271895 under ICR 202506-0920-008 · OMB 0920-1446.

Documents and Forms

Document Name Document Type
Form 0920-25AU Baseline survey Form
Form 0920-25AU Initial Clinical Survey Baseline survey Form
0920-25AU Initial Clinical Survey Attachment_3_Initial_clinical_survey.docx Form
0920-25AU Initial Clinical Survey Attachment_3_Initial_clinical_survey.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Baseline survey	Agency IC Tracking Number:	0920-25AU

Is this a Common Form? No		IC Status: Modified

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	0920-25AU	Initial Clinical Survey	Attachment_3_Initial_clinical_survey.docx		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 %

	Approved	Change Due to Potential Violation of the PRA
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

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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