View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	Baseline	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 and Instruction	Client Baseline Interview				Yes	Yes	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,885	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	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	5,885	0	0	0	0	5,885
Annual IC Time Burden (Hours)	1,942	0	0	0	0	1,942
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
SAMHSA Response to OMB		03/14/2014
Client Interview Script		03/14/2014
Client Interview Consent Form		03/14/2014

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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