Information Collection

Clinic Visit - Case Parent

IC 178552 under ICR 200702-0920-001 · OMB 0920-0741.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0741 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix F.1 ADI-R.pdf	Other-ADI-R
Appendix F.2 EDQ.doc	Other-Early Development Questionnair
Appendix F.3 Services and Treatment Q.doc	Other-Services and Treatments Interv
Appendix F.4 Vineland.pdf	Other-Vineland Adaptive Behavior Sca
Appendix E 3 Informed Consent Case 2007 06.doc	Other-Written Informed Consent Form
Appendix E.3 Informed Consent NIC&Sub6-4-2007.doc	Other-Written Informed Consent Docum

IC Title:

Clinic Visit - Case Parent

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Written Informed Consent Form	Appendix E 3 Informed Consent Case 2007 06.doc	Yes	Yes	Printable Only
Other-Written Informed Consent Document	Appendix E.3 Informed Consent NIC&Sub6-4-2007.doc	Yes	Yes	Printable Only
Other-Services and Treatments Interview	Appendix F.3 Services and Treatment Q.doc	Yes	Yes	Printable Only
Other-Early Development Questionnaire	Appendix F.2 EDQ.doc	Yes	Yes	Printable Only
Other-ADI-R	Appendix F.1 ADI-R.pdf	Yes	Yes	Printable Only
Other-Vineland Adaptive Behavior Scales	Appendix F.4 Vineland.pdf	Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 810

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,050	4,050
Annual IC Time Burden (Hours)	2,700	2,700
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.