Information Collection

Parent Outcome Baseline Survey

IC 201399 under ICR 201207-0920-010 · OMB 0920-0941.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0941 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 5 Parent Outcome Baseline Survey	Form and Instruction
5 Attachment H: Parent Outcome Survey (Baseline) Atmt H - Parent Outcome Baseline Survey.docx	Form and Instruction
no form number Parent Outcome Survey Baseline Atmt_H_Parent_Outcome_Survey_Baseline7_23_2012.doc	Form and Instruction
Atmt VV Parent Program Participant Consent Form.docx Atmt VV Parent Program Participant Consent Form	IC Document
Atmt SSS Screen shots parent survey_11-22-11 BT.doc Atmt SSS Screen shots parent survey_11-22-11 BT	IC Document

IC Title:

Parent Outcome Baseline Survey

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 and Instruction	5	Attachment H: Parent Outcome Survey (Baseline)	Atmt H - Parent Outcome Baseline Survey.docx		No	No	Paper Only
Form and Instruction	no form number	Parent Outcome Survey Baseline	Atmt_H_Parent_Outcome_Survey_Baseline7_23_2012.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,919

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,919	-505	2,424
Annual IC Time Burden (Hours)	1,919	-505	2,424
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Atmt VV Parent Program Participant Consent Form	Atmt VV Parent Program Participant Consent Form.docx	02/27/2012
Atmt SSS Screen shots parent survey_11-22-11 BT	Atmt SSS Screen shots parent survey_11-22-11 BT.doc	02/27/2012

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