Information Collection

Baseline survey for adults (Instrument 10)

IC 220539 under ICR 202005-0970-006 · OMB 0970-0481.

Documents and Forms

Document Name Document Type
Instrument 10_STREAMS_Adult baseline survey_2-26-16.docx Other-Baseline Survey

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Baseline survey for adults (Instrument 10)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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-Baseline Survey			Instrument 10_STREAMS_Adult baseline survey_2-26-16.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: 200	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	100	100
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.