Information Collection

Great Lakes Medical and Allied Health Care Providers Follow-up

IC 204242 under ICR 201209-0920-008 · OMB 0920-0954.

Documents and Forms

Documents and forms in this information collection
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

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.