Information Collection

Asessment and Referral Tool

IC 201610 under ICR 201203-0930-002 · OMB 0930-0270.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0270 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Asessment and Referral Tool	Form and Instruction
Adult Assessment and Referral tool Attachment_D_AdultAssessmentandReferralTool 7.31.12.docx	Form and Instruction
Child Youth Assessment and Referral Tool Attachment_E_ChildYouthAssessmentandReferralTool 7.31.12.docx	Form and Instruction

IC Title:

Asessment and Referral Tool

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 and Instruction	N/A	Adult Assessment and Referral tool	Attachment_D_AdultAssessmentandReferralTool 7.31.12.docx		Yes	Yes	Paper Only
Form and Instruction	N/A	Child Youth Assessment and Referral Tool	Attachment_E_ChildYouthAssessmentandReferralTool 7.31.12.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 200

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	2,800	2,800
Annual IC Time Burden (Hours)	700	700
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.