Information Collection

A-CASI 3-Month Follow-up

IC 194318 under ICR 201008-0920-009 · OMB 0920-0872.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form no number A-CASI 3-Month Follow-up	Form
no number A-CASI Attachment 3b_Quantitative Survey Measures.07092010.docx	Form
3b Quantiative Survey Attachment 3b_Quantitative Survey Measures11012010.docx	Form

IC Title:

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	no number	A-CASI	Attachment 3b_Quantitative Survey Measures.07092010.docx		Yes	Yes	Fillable Fileable
Form	3b	Quantiative Survey	Attachment 3b_Quantitative Survey Measures11012010.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 300

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	150	150
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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