Services Planned and Provided

Fetal Alcohol Spectrum Disorders (FASD) Center for Excellence Diagnosis and Intervention Project

Documents and Forms

Document Name Document Type
Form Form D - DxInt.Ser Services Planned and Provided Form and Instruction
Form D - DxInt.Ser Form D - DxInt.Service Provided After Diag. D- DxInt.Service Provided After Diag.doc Form and Instruction
Consent forms.pdf Consent Forms IC Document

Information Collection (IC) Details

IC Title:	Services Planned and Provided	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	Form D - DxInt.Service Provided After Diag.	Form D - DxInt.Service Provided After Diag.	D- DxInt.Service Provided After Diag.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 800	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	800	800
Annual IC Time Burden (Hours)	265	265
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Consent Forms	Consent forms.pdf	05/27/2010

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