We-based interviews

Campaign Within the Latino Community on Right to Non-Discrimination in Certain Health and Human Service Programs

Documents and Forms

Document Name Document Type
Attachment 4 -Questionnaire for Online Survey docx 4 24 12 (REV) .docx Other-Survey

Information Collection (IC) Details

IC Title:	We-based interviews	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 4 -Questionnaire for Online Survey docx 4 24 12 (REV) .docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 600	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	600	600
Annual IC Time Burden (Hours)	170	170
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.