Information Collection

Clinical Assesment Baseline & Final

IC 263497 under ICR 202602-0920-002 · OMB 0920-1428.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-26-0026 Clinic Assessment Baseline and Final Clinical Assesment Baseline & Final	Form and Instruction
0920-26-0026 Clinic Assessment Baseline and Final Att 4l_Clinic Assessment Baseline and Final_Clean.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-26-0026

Is this a Common Form? Yes

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	0920-26-0026				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	4	0	4
Annual IC Time Burden (Hours)	9	1	8
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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].