Household Roster--Main: Baseline & Follow-up 2 Replenishment

The Real Cost Campaign Outcomes Evaluation Study: Cohort 3 (Outcomes Study)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0910-0915 can be found here:

Documents and Forms

Document Name Document Type
Attachment 1. Parent Guardian Mail Screener.docx Other-ENGLISH Parent Guardian Mail S
Attachment 1. Parent Guardian Mail Screener.docx Other-ENGLISH Parent Guardian Mail S
Attachment 1. Parent Guardian Mail Screener_rev_SPA_FINAL.docx Other-SPANISH Parent Guardian Mail S
Attachment 1. Parent Guardian Mail Screener_rev_SPA_FINAL.docx Other-SPANISH Parent Guardian Mail S

Information Collection (IC) Details

IC Title:	Household Roster--Main: Baseline & Follow-up 2 Replenishment	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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-ENGLISH Parent Guardian Mail Screener			Attachment 1. Parent Guardian Mail Screener.docx		No		Paper Only
Other-SPANISH Parent Guardian Mail Screener			Attachment 1. Parent Guardian Mail Screener_rev_SPA_FINAL.docx		No		Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 99 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	5,500	5,500
Annual IC Time Burden (Hours)	440	440
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.