Information Collection

Behavioral Assessment

IC 200523 under ICR 201112-0920-011 · OMB 0920-0928.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Behavioral Assessment	Form
Behavioral Assessment - Spanish version Att 3b Behavioral Assessment Survey (Spanish).docx	Form
Behavioral Assessment Survey (English) Att 2b Behavioral Assessment Survey.docx	Form
Att 2c Screen Shots of Survey.pdf Att 2c - Screenshots	IC Document

IC Title:

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	none	Behavioral Assessment - Spanish version	Att 3b Behavioral Assessment Survey (Spanish).docx		Yes	Yes	Fillable Fileable
Form	none	Behavioral Assessment Survey (English)	Att 2b Behavioral Assessment Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 170,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	170,000	170,000
Annual IC Time Burden (Hours)	39,667	39,667
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 2c - Screenshots	Att 2c Screen Shots of Survey.pdf	12/15/2011

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