Baseline Survey

Doing It For Ourselves (DIFO) Program

Documents and Forms

Document Name Document Type
Baseline Survey (DIFO) Doing It For Ourselves REV. 8-22-13.DOCX Other-survey
Baseline Survey (DIFO) SurveyMonkey Screenshots 8-26-2013.DOCX Other-ScreenShot

Information Collection (IC) Details

IC Title:	Baseline Survey	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
Other-survey			Baseline Survey (DIFO) Doing It For Ourselves REV. 8-22-13.DOCX		No	No	Paper Only
Other-ScreenShot			Baseline Survey (DIFO) SurveyMonkey Screenshots 8-26-2013.DOCX		No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 168	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
Annual Number of Responses for this IC	168	168
Annual IC Time Burden (Hours)	84	84
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.