Screener for Parents for Post-Implementation Survey

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 4 Screener for Parents for Post-Implementation Survey Form
4 Screener for Parents for Post-Implementation Survey-Span Att 3B Screener for Parents (Spanish) 9 9 11.docx Form
3 Screener for Parents for Post Implemention Survey-Englis Att 3A Screener for Parents (English) 9 9 11.docx Form

Information Collection (IC) Details

IC Title:	Screener for Parents for Post-Implementation Survey	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	4	Screener for Parents for Post-Implementation Survey-Spanish	Att 3B Screener for Parents (Spanish) 9 9 11.docx		Yes	No	Paper Only
Form	3	Screener for Parents for Post Implemention Survey-English	Att 3A Screener for Parents (English) 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.