Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Client Eligibility Documentation Form New 4478 358 0 Other-Client Eligibility Documentation Form
Client Process Evaluation Interview Modified 169 85 0 Other-Client Process Evaluation Interview
Other-Appendix I. Client Process Evaluation Interview
Grantee Process Evaluation Online Survey Year 1 New 32 128 0 Other-Grantee Process Evaluation Online Survey Year 1
Grantee Site Visit Interview Guide New 10 20 0 Other-Grantee Site Visit Interview Guide
Home Hazard Checklist (Baseline) Unchanged 3000 1260 0 Other-Home Hazard Checklist (Baseline)
Other-Home Hazard Checklist (Baseline)
Home Hazard Checklist (Post-modification) Modified 1688 709 0 Other-Home Hazard Checklist (Post-modification)
Other-Home Hazard Checklist (Post-modification)
Lost-to-Project Form New 2790 223 0 Other-Lost-to-Project Form
OAHM Client Impact Evaluation Interview (Baseline) Modified 2250 743 0 Other-OAHM Client Impact Evaluation Interview (Baseline)
Other-OAHM Client Impact Evaluation Interview (Baseline)
OAHM Client Impact Evaluation Interview (Post-modification) Modified 1688 557 0 Other-OAHM Client Impact Evaluation Interview (Post-modification)
Other-OAHM Client Impact Evaluation Interview (Post-modification)
OAHM Client Program Questionnaire (Baseline) Unchanged 3000 300 0 Other-OAHM Client Program Questionnaire (Baseline)
Other-OAHM Client Program Questionnaire (Baseline)
OAHM Client Program Questionnaire (Post-modification) Modified 1688 169 0 Other-OAHM Client Program Questionnaire (Post-modification)
Other-OAHM Client Program Questionnaire (Post-modification)
OAHM Program Documentation of Work Completed Form New 2250 1125 0 Other-OAHM Program Documentation of Work Completed Form
OAHM Program Evaluation Informed Consent Modified 2250 563 0 Other-OAHM Program Evaluation Informed Consent
Other-OAHM Program Evaluation Informed Consent
Script to Schedule Client Process Evaluation Interview Modified 188 15 0 Other-Script to Schedule Client Process Evaluation Interview
Other-Script to Schedule Client Process Evaluation Interview
Total burden requested under this ICR: 25481 6255 0  
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