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

Evaluating Reach, Awareness, and Exposure of Enhanced Implementation of the Learn the Signs. Act Early. Campaign in Four Target Sites

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

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.