Information Collection

Follow-up Assessment of Matter of Balance Programs

IC 188658 under ICR 201003-0920-004 · OMB 0920-0818.

Documents and Forms

Document Name Document Type
Follow-up Assessment of Matter of Balance Programs Form
Follow-up Assessment for Matter of Balance Programs Attachment_2_-_Follow-up_assessment_questionnaire_02-03-10.doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Follow-up Assessment of Matter of Balance Programs	Agency IC Tracking Number:

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	none	Follow-up Assessment for Matter of Balance Programs	Attachment_2_-_Follow-up_assessment_questionnaire_02-03-10.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 142	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	142	-283	425
Annual IC Time Burden (Hours)	107	-212	319
Annual IC Cost Burden (Dollars)	0	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.