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Baseline Interview
Community-based Organization (CBO) Monitoring and Evaluation Project of RESPECT (CMEP-RESPECT)
OMB: 0920-0895
IC ID: 198825
OMB.report
HHS/CDC
OMB 0920-0895
ICR 201406-0920-004
IC 198825
( )
Documents and Forms
Document Name
Document Type
Form 3
Baseline Interview
Form and Instruction
3 Baseline Interview
Att 5a_Baseline Survey.pdf
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Baseline Interview
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Removed
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
Form and Instruction
3
Baseline Interview
Att 5a_Baseline Survey.pdf
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Immunization Management
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
400
Number of Respondents for Small Entity:
400
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
0
0
-400
0
0
400
Annual IC Time Burden (Hours)
0
0
-133
0
0
133
Annual IC Cost Burden (Dollars)
0
0
0
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.