Information Collection

Bright Futures for Women's Health and Wellness

IC 180330 under ICR 200705-0915-007 · OMB 0915-0308.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
bf adult form.doc	Other-Adult Women Survey
bf Youth Form.doc	Other-Youth survey
bf adult guide.pdf bf adult guide	IC Document
bf adult tip sheets.pdf bf adult tip sheets	IC Document
bf young women wallet card.pdf bf young women wallet card	IC Document
bf youth guide.pdf bf youth guide	IC Document
bf Parent Consent Form.doc bf Parent Consent Form	IC Document
bf Provider Consent Form.doc bf Provider Consent Form	IC Document
bf Youth Assent Form.doc bf Youth Assent Form	IC Document
bf Adult Consent Form.doc bf Adult Consent Form	IC Document

IC Title:

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	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Adult Women Survey			bf adult form.doc		No	No	Paper Only
Other-Youth survey			bf Youth Form.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,000

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	3,000	3,000
Annual IC Time Burden (Hours)	2,430	2,430
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
bf adult guide	bf adult guide.pdf	05/10/2007
bf adult tip sheets	bf adult tip sheets.pdf	05/10/2007
bf young women wallet card	bf young women wallet card.pdf	05/10/2007
bf youth guide	bf youth guide.pdf	05/10/2007
bf Parent Consent Form	bf Parent Consent Form.doc	05/10/2007
bf Provider Consent Form	bf Provider Consent Form.doc	05/10/2007
bf Youth Assent Form	bf Youth Assent Form.doc	05/10/2007
bf Adult Consent Form	bf Adult Consent Form.doc	05/10/2007

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