Information Collection

Baseline Assessment

IC 232934 under ICR 202010-0920-005 · OMB 0920-1246.

Documents and Forms

Document Name Document Type
Baseline Assessment Form
TLC Baseline Assessment Screen Shot.pdf Other-Example Screen Shots of a Comp
TLC Baseline Assessment Appendix E Baseline Assessment_COVID_11Sep2020_clean.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Baseline Assessment	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	n/a	TLC Baseline Assessment	Appendix E Baseline Assessment_COVID_11Sep2020_clean.docx		Yes	Yes	Fillable Fileable
Other-Example Screen Shots of a Completed Baseline Assessment			TLC Baseline Assessment Screen Shot.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems HHS/CDC	FR Citation: 57 FR 62812

Number of Respondents: 75	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	75	75
Annual IC Time Burden (Hours)	75	75
Annual IC Cost Burden (Dollars)	1,826	1,826

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.