Information Collection

Self-Administered Questionnaire

IC 216605 under ICR 201505-1291-001 · OMB 1291-0004.

Documents and Forms

Document Name Document Type
Appendix C2 SAQ 5-15.docx Other-Self-Administered Questionnair

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Self-Administered Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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
Other-Self-Administered Questionnaire			Appendix C2 SAQ 5-15.docx		No		Paper Only

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5,500	5,500
Annual IC Time Burden (Hours)	644	644
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.