Information Collection

MUH Resident Baseline Survey - screening LA county

IC 204440 under ICR 201210-0920-003 · OMB 0920-1004.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1004 can be found here:

Documents and Forms

Document Name Document Type
MUH Resident Baseline Survey - screening LA county Form
Resident Baseline Survey - screener - English Att 8A(e)_MUH Resident Baseline Survey_8 30 2012.doc Form
Resident Baseline Survey - screener Spanish Att 8A(s)_MUH Resident Baseline Survey_8 30 2012.doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	MUH Resident Baseline Survey - screening LA county	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
Form	none	Resident Baseline Survey - screener - English	Att 8A(e)_MUH Resident Baseline Survey_8 30 2012.doc		No	No	Paper Only
Form	none	Resident Baseline Survey - screener Spanish	Att 8A(s)_MUH Resident Baseline Survey_8 30 2012.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 833	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	833	833
Annual IC Time Burden (Hours)	69	69
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.