Information Collection

Six and Twelve Month Follow-up Questionnaire - for Environment

IC 198573 under ICR 201112-0920-013 · OMB 0920-0906.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0906 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Six and Twelve Month Follow-up Questionnaire - for Environment	Form
6 and 12 month Follow-up - Environment Appendix D7 -6 & 12-mo Follow-up (Environment) 7-1-2011.doc	Form
6 & 12-mo Follow-up (Environment) Chinese version - November 30, 2011.doc 6 and 12 month - environment - Chinese	IC Document
6 & 12-mo Follow-up (Environment) SPANISH - November 30, 2011.doc 6 and 12 month - environment - Spanish	IC Document

IC Title:

Six and Twelve Month Follow-up Questionnaire - for Environment

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	6 and 12 month Follow-up - Environment	Appendix D7 -6 & 12-mo Follow-up (Environment) 7-1-2011.doc		Yes	No	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title: Epidemiological Studies and Surveillance of Disease Problems 09-20-0136

FR Citation: 57 FR 62812

Number of Respondents: 832

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	Previously Approved
Annual Number of Responses for this IC	1,664	1,664
Annual IC Time Burden (Hours)	277	277
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
6 and 12 month - environment - Chinese	6 & 12-mo Follow-up (Environment) Chinese version - November 30, 2011.doc	12/14/2011
6 and 12 month - environment - Spanish	6 & 12-mo Follow-up (Environment) SPANISH - November 30, 2011.doc	12/14/2011

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