Information Collection

Fasd - Choices

IC 189906 under ICR 200907-0930-001 · OMB 0930-0303.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Attachment I FASD - CHOICES	Form and Instruction
Attachment I Forms Forms- Attachment I.zip	Form and Instruction
List of sites- Attachment II.doc Attachment II - List of Sites	IC Document
Consent Forms- Attachment III.zip Attachment III - Consent	IC Document

IC Title:

FASD - CHOICES

Agency IC Tracking Number:

Is this a Common Form?

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 I	Forms	Forms- Attachment I.zip		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,053

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	5,701	5,701
Annual IC Time Burden (Hours)	844	844
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment II - List of Sites	List of sites- Attachment II.doc	07/13/2009
Attachment III - Consent	Consent Forms- Attachment III.zip	07/13/2009

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