Information Collection

Midwest Modified Index Collaboration Pre-test and Follow-up

IC 204265 under ICR 201209-0920-008 · OMB 0920-0954.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Midwest Modified Index Collaboration Pre-test and Follow-up	Form
Midwest Modified Index Collaboration Pre-test and Follow F7a_screenshots Midwest FASD RTC Modified Index of Interdisciplinary Collab, 3 mo Follow-up - online survey.pdf	Form
F7_Midwest FASD Regional Training Center Modified Index of Interdisciplinary Collab, Pre-Test.docx Midwest Modified Index Colloboration Pre-test and 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	Midwest Modified Index Collaboration Pre-test and Follow-up	F7a_screenshots Midwest FASD RTC Modified Index of Interdisciplinary Collab, 3 mo Follow-up - online survey.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: 75

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	150	150
Annual IC Time Burden (Hours)	25	25
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Midwest Modified Index Colloboration Pre-test and Follow-up - Word	F7_Midwest FASD Regional Training Center Modified Index of Interdisciplinary Collab, Pre-Test.docx	09/19/2012

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