Information Collection

SAMHSA Fetal Alcohol Spectrum Disorders Center for Excellence Screening and Brief Intervention Evaluation

IC 189113 under ICR 200905-0930-001 · OMB 0930-0302.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0302 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Attachment 1 - Ins SAMHSA Fetal Alcohol Spectrum Disorders Center for Excellence Screening and Brief Intervention Evaluation	Form and Instruction
Attachment 1 - Ins Attachment 1 - Instruments AttachmentI-Surveys.zip	Form and Instruction
Attachment II & III.zip Attachments 2 & 3	IC Document

IC Title:

SAMHSA Fetal Alcohol Spectrum Disorders Center for Excellence Screening and Brief Intervention Evaluation

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
Form and Instruction	Attachment 1 - Instruments	Attachment 1 - Instruments	AttachmentI-Surveys.zip		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,428

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	17,998	17,998
Annual IC Time Burden (Hours)	3,771	3,771
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachments 2 & 3	Attachment II & III.zip	05/05/2009

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