Grantee Baseline Survey

Rural Public Health Workforce Training Network Program (RPHWTN)

Documents and Forms

Document Name Document Type
Form 1 Grantee Baseline Survey Form
1 Grantee Baseline Survey Attachment2_RPHWTNPGranteeBaselineSurvey.pdf Form
1 Grantee Baseline Survey Attachment2_RPHWTNPGranteeBaselineSurvey.pdf Form

Information Collection (IC) Details

IC Title:	Grantee Baseline Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	Grantee Baseline Survey	Attachment2_RPHWTNPGranteeBaselineSurvey.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 32	Number of Respondents for Small Entity: 20

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	32	32
Annual IC Time Burden (Hours)	8	8
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.