MUH Resident Baseline Survey - Children's Module LA

Adoption, Health Impact and Cost of Smoke-Free Multi-Unit Housing Policies

Documents and Forms

Document Name Document Type
MUH Resident Baseline Survey - Children's Module LA Form
MUH Resident Baseline - Children's Module section G clean 12.17.13Att 8A(e)_MUH Resident Baseline Survey.doc Form
MUH Resident Baseline - Children's Module section G Span clean 12.17.13 Att 8A(s)_MUH Resident Baseline Survey_12.15.13.doc Form
clean 12.17.13 Att 8A-1(e) MUH Resident Adult Participant Consent_9.3.......docx Consent Adult IC Document
clean 12 17. 13 Att 8A-1(s) MUH Resident Adult Participant Consent_9 3 1....docx Consent Adult Spanish IC Document
Att 8A-2(e) MUHAdult Resident HIPPA form_9.3.13.docx IRB Authorization IC Document
Att 8A-2(s) MUHAdult Resident HIPPA form 9.3.13.docx IRB Authoization Spanish IC Document
clean 12.17.13 Att 8A-3(e) LA Resident Consent for Child Questions_9.3......docx Consent Child IC Document
clean 12 17 13 Att 8A-3(s) LA Resident Consent for Child Questions_9 3 1....docx Consent Child Spanish IC Document

Information Collection (IC) Details

IC Title:	MUH Resident Baseline Survey - Children's Module LA	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	MUH Resident Baseline - Children's Module section G	clean 12.17.13Att 8A(e)_MUH Resident Baseline Survey.doc		Yes	No	Fillable Printable
Form	none	MUH Resident Baseline - Children's Module section G Spanish	clean 12.17.13 Att 8A(s)_MUH Resident Baseline Survey_12.15.13.doc		Yes	No	Fillable Printable

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 %

	Approved	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
Consent Adult	clean 12.17.13 Att 8A-1(e) MUH Resident Adult Participant Consent_9.3.......docx	12/19/2013
Consent Adult Spanish	clean 12 17. 13 Att 8A-1(s) MUH Resident Adult Participant Consent_9 3 1....docx	12/19/2013
IRB Authorization	Att 8A-2(e) MUHAdult Resident HIPPA form_9.3.13.docx	09/23/2013
IRB Authoization Spanish	Att 8A-2(s) MUHAdult Resident HIPPA form 9.3.13.docx	09/23/2013
Consent Child	clean 12.17.13 Att 8A-3(e) LA Resident Consent for Child Questions_9.3......docx	12/19/2013
Consent Child Spanish	clean 12 17 13 Att 8A-3(s) LA Resident Consent for Child Questions_9 3 1....docx	12/19/2013

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