Information Collection

Adult Follow-up - Screenshot

IC 209242 under ICR 201311-0925-001 · OMB 0925-0685.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0685 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 5 Adult Follow-up - Screenshot	Form
5 Adult Follow-up Attachment 22 - Screenshot Adult Followup - MDF.zip	Form
Attachment_5_-_Data_collection_instrument_-_Adult_questionnaire_Followup_MDF[1].pdf Adult Follow-up	IC Document

IC Title:

Adult Follow-up - Screenshot

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	5	Adult Follow-up	Attachment 22 - Screenshot Adult Followup - MDF.zip		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: SORN 09-25-0200

FR Citation: 67 FR 60741

Number of Respondents: 200

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	200	200
Annual IC Time Burden (Hours)	150	150
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Adult Follow-up	Attachment_5_-_Data_collection_instrument_-_Adult_questionnaire_Followup_MDF[1].pdf	11/06/2013

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