Information Collection

Suicide _VA

IC 213737 under ICR 201311-0920-016 · OMB 0920-1011.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1011 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Suicide _VA	Form
Interview Guide Appendix 1. Administrator and Counselor Interview Guide.doc	Form
Focus Group Guide Appendix 2. Parent Focus Group Guide.doc	Form
Letter of Invitation - Fairfax County.pdf Letter of Inviatation	IC Document
2015002-XXX Suicide_VA v2.docx Request for Approval	IC Document

IC Title:

Suicide _VA

Agency IC Tracking Number:

15DS

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 301 [241]

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	none	Interview Guide	Appendix 1. Administrator and Counselor Interview Guide.doc		No		Paper Only
Form	none	Focus Group Guide	Appendix 2. Parent Focus Group Guide.doc		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0113 Epidemic Investigation Case Records

FR Citation: 51 FR 42466

Number of Respondents: 105

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	105	105
Annual IC Time Burden (Hours)	98	98
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Letter of Inviatation	Letter of Invitation - Fairfax County.pdf	11/04/2014
Request for Approval	2015002-XXX Suicide_VA v2.docx	11/05/2014

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