Great Lakes Medical and Allied Health Care Providers Follow-up

Fetal Alcohol Spectrum Disorders Regional Training Centers

Documents and Forms

Document Name Document Type
Great Lakes Medical and Allied Health Care Providers Follow-up Form
Foundations Online Follow-up E3a_screenshots Great Lakes FASD RTC QUALTRICS Foundatio 6mo.pdf Form
E3_Great Lakes FASD RTC Foundations of FASD 6moFU.docx Foundations Online Follow-up - Word IC Document

Information Collection (IC) Details

IC Title:	Great Lakes Medical and Allied Health Care Providers Follow-up	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	none	Foundations Online Follow-up	E3a_screenshots Great Lakes FASD RTC QUALTRICS Foundatio 6mo.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 310	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	310	310
Annual IC Time Burden (Hours)	26	26
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Foundations Online Follow-up - Word	E3_Great Lakes FASD RTC Foundations of FASD 6moFU.docx	09/13/2012

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