Information Collection

Great Lakes Health Care Providers SBI Pre-test

IC 204243 under ICR 201209-0920-008 · OMB 0920-0954.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Great Lakes Health Care Providers SBI Pre-test	Form
SBI Pre-test E4a_screenshots Great Lakes FASD RTC QUALTRICS Screenin.pdf	Form
E4_Great Lakes FASD RegionalTraining Center Screening and Brief.docx SBI Pre-test - 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	SBI Pre-test	E4a_screenshots Great Lakes FASD RTC QUALTRICS Screenin.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: 120

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	120	120
Annual IC Time Burden (Hours)	16	16
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SBI Pre-test - Word	E4_Great Lakes FASD RegionalTraining Center Screening and Brief.docx	09/13/2012

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