Information Collection

Screener for Parents (English 3A), (Spanish 3B)

IC 200246 under ICR 201111-0920-006 · OMB 0920-0911.

Documents and Forms

Document Name Document Type
Form 1 Screener for Parents (English 3A), (Spanish 3B) Form
1 Screener for Parents--English 3A Att 3A Screener for Parents (English) 9 9 11.docx Form
2 Screener for Parents--Spanish 3B Att 3B Screener for Parents (Spanish) 9 9 11.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Screener for Parents (English 3A), (Spanish 3B)	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	1	Screener for Parents--English 3A	Att 3A Screener for Parents (English) 9 9 11.docx		Yes	No	Paper Only
Form	2	Screener for Parents--Spanish 3B	Att 3B Screener for Parents (Spanish) 9 9 11.docx		Yes	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,200	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,200	1,200
Annual IC Time Burden (Hours)	60	60
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.