Fasd - Cfe - Sbi - Choices

SAMHSA Fetal Alcohol Spectrum Disorders Center for Excellence Screening and Brief Intervention Project and Project CHOICES Evaluation

Documents and Forms

Document Name Document Type
Form FormB_SBI_Process FASD - CFE - SBI - CHOICES Form and Instruction
FormB_SBI_Process FormB_SBI_Process FormB_SBI_Process_7-2-13.doc Form and Instruction
FormA_Assessment_T FormA_Assessment_Tool FormA_Assessment_Tool_7-2-13.doc Form and Instruction
FormC_Client_Satis FormC_Client_Satisfaction FormC_Client_Satisfaction_7-2-13.doc Form and Instruction

Information Collection (IC) Details

IC Title:	FASD - CFE - SBI - CHOICES	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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	FormB_SBI_Process	FormB_SBI_Process	FormB_SBI_Process_7-2-13.doc	Yes	Yes	Fillable Printable
Form and Instruction	FormA_Assessment_Tool	FormA_Assessment_Tool	FormA_Assessment_Tool_7-2-13.doc	Yes	Yes	Fillable Printable
Form and Instruction	FormC_Client_Satisfaction	FormC_Client_Satisfaction	FormC_Client_Satisfaction_7-2-13.doc	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10,493	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	18,000	2	17,998
Annual IC Time Burden (Hours)	4,176	405	3,771
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.