Administrators

Community Support Evaluation

Documents and Forms

Document Name Document Type
Form SSA KII Administra Administrators Form and Instruction
SSA KII Administra SSA KII Administrator Version Attachment L_SSA KII Administrator Version (Y2-Y4).docx Form and Instruction
Attachment Q_SSA KII Verbal Consent Script.docx SSA KII Verbal Consent Script IC Document

Information Collection (IC) Details

IC Title:	Administrators	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
Form and Instruction	SSA KII Administrator Version	SSA KII Administrator Version	Attachment L_SSA KII Administrator Version (Y2-Y4).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 14	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 Agency Discretion
Annual Number of Responses for this IC	14	14
Annual IC Time Burden (Hours)	14	14
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SSA KII Verbal Consent Script	Attachment Q_SSA KII Verbal Consent Script.docx	03/10/2016

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