Information Collection

North Carolina Family Assessment Form

IC 198966 under ICR 201108-0930-002 · OMB 0930-0330.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0330 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form North Carolina Fam North Carolina Family Assessment Form	Form and Instruction
North Carolina Fam North Carolina Family Assessment Form Attachment B-NCFASGR[1].pdf	Form and Instruction

IC Title:

North Carolina Family Assessment Form

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	North Carolina Family Assessment Form	North Carolina Family Assessment Form	Attachment B-NCFASGR[1].pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 483

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	966	966
Annual IC Time Burden (Hours)	483	483
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.