Information Collection

36-month Adult Follow-up Survey

IC 209542 under ICR 201312-2528-001 · OMB 2528-0259.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2528-0259 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix B_36-Month Followup ADULT Survey.docx	Other-Adult Survey
Adult Consent Form Appendix A1_ 36-month consent_Adult Respondents_1_13.docx	Form
Release of Information Appendix A4_Release of Information_1_8.docx	Form
Parental Permission form Appendix A2_ Parental Permission Form_1_13.docx	Form

IC Title:

36-month Adult Follow-up Survey

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	Available Electronically?	Electronic Capability
Other-Adult Survey			Appendix B_36-Month Followup ADULT Survey.docx	No	Paper Only
Form	N/A	Adult Consent Form	Appendix A1_ 36-month consent_Adult Respondents_1_13.docx	No	Paper Only
Form	N/A	Release of Information	Appendix A4_Release of Information_1_8.docx	No	Paper Only
Form	N/A	Parental Permission form	Appendix A2_ Parental Permission Form_1_13.docx	No	Paper Only

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,712

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	1,712	1,712
Annual IC Time Burden (Hours)	2,140	2,140
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.