Midwest Modified Index Collaboration Pre-test and Follow-up

Fetal Alcohol Spectrum Disorders Regional Training Centers

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Midwest Modified Index Collaboration Pre-test and 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	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 %

	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

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.