Information Collection

Fasd - Choices

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.