Information Collection

Survey Instrument

IC 9803 under ICR 201205-0970-004 · OMB 0970-0033.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0033 can be found here:

Documents and Forms

Document Name Document Type
HHSP23320110005YC-Fully executed contract.pdf Other-Contract
1 Annual Survey Questionnaire for OMB - English FINAL 3-14-12.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Survey Instrument	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 4 CFR 45

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Contract			HHSP23320110005YC-Fully executed contract.pdf		No	No	Fillable Printable
Form and Instruction	1	Annual Survey	Questionnaire for OMB - English FINAL 3-14-12.pdf		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: 2,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,500	500	2,000
Annual IC Time Burden (Hours)	1,567	314	1,253
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.