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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.