Supplemental Baseline Questions (program participants and control group members)

Health Profession Opportunity Grants (HPOG) program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0394 can be found here:

Documents and Forms

Document Name Document Type
Instrument 1_Supplemental Baseline Data 6-7-12.doc Other-Supplemental Questions

Information Collection (IC) Details

IC Title:	Supplemental Baseline Questions (program participants and control group members)	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
Other-Supplemental Questions			Instrument 1_Supplemental Baseline Data 6-7-12.doc		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: 5,250	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	5,250	125	5,125
Annual IC Time Burden (Hours)	1,313	32	1,281
Annual IC Cost Burden (Dollars)	0	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.