Information Collection

Fasd P-cap Crsq

IC 191210 under ICR 200911-0930-001 · OMB 0930-0309.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CRSQ FASD P-CAP CRSQ	Form and Instruction
CRSQ CRSQ 1 PCAP CRSQ.pdf	Form and Instruction
Attachment II and III.zip Attachment II and III	IC Document

IC Title:

FASD P-CAP CRSQ

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	CRSQ	CRSQ	1 PCAP CRSQ.pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 190

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	190	190
Annual IC Time Burden (Hours)	15	15
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment II and III	Attachment II and III.zip	10/27/2009

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