Information Collection

90-day follow-up Interview

IC 198827 under ICR 201406-0920-004 · OMB 0920-0895.

Documents and Forms

Document Name Document Type
90-day follow-up Interview Form
90 day Follow-up Survey att3a_90-Day Follow-up Survey.docx Form
90 day Follow-up Screenshots CMEP-RESPECT QDS Screen Shots 90-day Follow-up2.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	90-day follow-up Interview	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	90 day Follow-up Survey	att3a_90-Day Follow-up Survey.docx		Yes	Yes	Fillable Fileable
Form	none	90 day Follow-up Screenshots	CMEP-RESPECT QDS Screen Shots 90-day Follow-up2.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 320	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	320	320
Annual IC Time Burden (Hours)	96	96
Annual IC Cost Burden (Dollars)	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.