Information Collection

Two-Tier (High): 12-Month Visit Interview

IC 196545 under ICR 201103-0925-001 · OMB 0925-0593.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0593 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 78.1 Two-Tier (High): 12-Month Visit Interview	Form and Instruction
78.1 Survey 12-Month Mother Interview 20110211.docx	Form and Instruction
78.2 Survey 12-Month Mother SAQ 20110211.doc	Form and Instruction
12-Month Visit Information Sheet 20110211.docx 12-Month Visit Information Sheet 20110211	IC Document

IC Title:

Two-Tier (High): 12-Month Visit Interview

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	78.1	Survey	12-Month Mother Interview 20110211.docx		Yes	Yes	Paper Only
Form and Instruction	78.2	Survey	12-Month Mother SAQ 20110211.doc		Yes	Yes	Paper Only

Line of Business: General Science and Innovation

Subfunction: Scientific and Technological Research and Innovation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,644

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,644	1,644
Annual IC Time Burden (Hours)	822	822
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
12-Month Visit Information Sheet 20110211	12-Month Visit Information Sheet 20110211.docx	02/11/2011

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