Information Collection

Baseline data collection – study participants

IC 227914 under ICR 201708-0970-004 · OMB 0970-0506.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0506 can be found here:

Documents and Forms

Document Name Document Type
Attachment B Coaching Baseline Questionnaire_PUBLIC_v8_clean.docx Other-Survey
Attachment J Baseline Survey QxQ_PUBLIC_v7_clean.docx Attachment J - Question-by-Question Justification - Baseline IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Baseline data collection â study participants	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-Survey			Attachment B Coaching Baseline Questionnaire_PUBLIC_v8_clean.docx		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: 2,000	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	2,000	2,000
Annual IC Time Burden (Hours)	660	660
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment J - Question-by-Question Justification - Baseline	Attachment J Baseline Survey QxQ_PUBLIC_v7_clean.docx	03/14/2018

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.