Information Collection

MI/SP Counselor Follow-up Questionnaire

IC 205813 under ICR 201302-0930-001 · OMB 0930-0274.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0274 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Follow-up Question MI/SP Counselor Follow-up Questionnaire	Form and Instruction
Follow-up Question Follow-up Questionnaire Attachment F_Counselor Follow up Questionnaire.pdf	Form and Instruction

IC Title:

MI/SP Counselor Follow-up Questionnaire

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 and Instruction	Follow-up Questionnaire	Follow-up Questionnaire	Attachment F_Counselor Follow up Questionnaire.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

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: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,250	1,250
Annual IC Time Burden (Hours)	213	213
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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