Service Receipt Questionnaire

Office of Community Services Affordable Housing and Supportive Services Demonstration Data Collection

Documents and Forms

Document Name Document Type
Instrument 2 Service_Receipt_Questionnaire.docx Other-Questionnaire
Instrument 2 Service_Receipt_Questionnaire.docx Other-Questionnaire

Information Collection (IC) Details

IC Title:	Service Receipt Questionnaire	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-Questionnaire			Instrument 2 Service_Receipt_Questionnaire.docx		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: 680	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	680	-440	1,120
Annual IC Time Burden (Hours)	170	-110	280
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.