Information Collection

Instrument 1 – Participant Survey

IC 254509 under ICR 202506-3135-002 · OMB 3135-0146.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Instrument 1 Instrument 1 – Participant Survey	Form and Instruction
Form Instrument 1 Participant Survey Instrument 1 – Participant Survey	Form and Instruction
Instrument 1 Participant Survey Instrument 1 – Participant Survey.pdf	Form and Instruction
Instrument 1 Participant Survey Instrument 1 – Participant Survey.pdf	Form and Instruction

IC Title:

Instrument 1 â Participant 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	Instrument 1				Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 400

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 75 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	800	100	700
Annual IC Time Burden (Hours)	128	16	112
Annual IC Cost Burden (Dollars)	0	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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