Information Collection

6-Month Follow-up Questionnaire

IC 199774 under ICR 201110-0920-008 · OMB 0920-0913.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0913 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment 3g 3- and 6-month Follow up Questionnaire 6.16.11.doc	Other-WORD
Att 3j Follow-up interview log 082511.docx Att 3j Follow-up interview log 082511	IC Document

IC Title:

6-Month Follow-up Questionnaire

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 241

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
Other-WORD			Attachment 3g 3- and 6-month Follow up Questionnaire 6.16.11.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 400

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	400	400
Annual IC Time Burden (Hours)	400	400
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 3j Follow-up interview log 082511	Att 3j Follow-up interview log 082511.docx	10/14/2011

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