2. MUSE Caregiver Baseline Survey

Multi-Site Implementation Evaluation of Tribal Home Visiting

Documents and Forms

Document Name Document Type
2. MUSE Caregiver Baseline Survey FINAL_1.17.2019.pdf Other-Caregiver Baseline Survey
2. MUSE Caregiver Baseline Survey by Phone 12.19.19_clean.docx Other-Caregiver Baseline Survey - PH

Information Collection (IC) Details

IC Title:	2. MUSE Caregiver Baseline Survey	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-Caregiver Baseline Survey			2. MUSE Caregiver Baseline Survey FINAL_1.17.2019.pdf		No		Paper Only
Other-Caregiver Baseline Survey - PHONE			2. MUSE Caregiver Baseline Survey by Phone 12.19.19_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: 188	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	188	188
Annual IC Time Burden (Hours)	47	47
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.