Information Collection

MUH Resident Baseline Survey - Children's Module - LA County

IC 204442 under ICR 201210-0920-003 · OMB 0920-1004.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1004 can be found here:

Documents and Forms

Document Name Document Type
MUH Resident Baseline Survey - Children's Module - LA County Form
Resident Survey - Children's Module - LA County -English Att 8A(e)_MUH Resident Baseline Survey_8 30 2012.doc Form
Resident Survey - Children's Module -LA County - Spanish Att 8A(s)_MUH Resident Baseline Survey_8 30 2012.doc Form
Att 8A-1(e)_MUH Resident Adult Consent.docx Adult Consent - English IC Document
Att 8A-1(s)_MUH Resident Adult Consent_8 30 2012.docx Adult Consent- Spanish IC Document
Att 8A-2(e)_LA HIPPA Form.docx LA HIPPA - English IC Document
Att 8A-2(s)_LA HIPPA Form_8 30 2012.docx LA HIPPA - Spanish IC Document
Att 8A-3(e)_LA Resident Consent for Child Questions.docx Child Consent - English IC Document
Att 8A-3(s)_LA Resident Consent for Child Questions_8 30 2012.docx Child Consent - Spanish IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	MUH Resident Baseline Survey - Children's Module - LA County	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	Resident Survey - Children's Module - LA County -English	Att 8A(e)_MUH Resident Baseline Survey_8 30 2012.doc		No	No	Paper Only
Form	none	Resident Survey - Children's Module -LA County - Spanish	Att 8A(s)_MUH Resident Baseline Survey_8 30 2012.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 250	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	250	250
Annual IC Time Burden (Hours)	63	63
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Adult Consent - English	Att 8A-1(e)_MUH Resident Adult Consent.docx	09/27/2012
Adult Consent- Spanish	Att 8A-1(s)_MUH Resident Adult Consent_8 30 2012.docx	09/27/2012
LA HIPPA - English	Att 8A-2(e)_LA HIPPA Form.docx	09/27/2012
LA HIPPA - Spanish	Att 8A-2(s)_LA HIPPA Form_8 30 2012.docx	09/27/2012
Child Consent - English	Att 8A-3(e)_LA Resident Consent for Child Questions.docx	09/27/2012
Child Consent - Spanish	Att 8A-3(s)_LA Resident Consent for Child Questions_8 30 2012.docx	09/27/2012

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