Information Collection

180-day Follow-up Interview

IC 198829 under ICR 201406-0920-004 · OMB 0920-0895.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
180-day Follow-up Interview	Form
180 day follow-up survey att3b_180-Day Follow-up Survey.docx	Form
180 day follow up survey screenshots CMEP-RESPECT QDS Screen Shots 180-day Follow-up.pdf	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	none	180 day follow-up survey	att3b_180-Day Follow-up Survey.docx		Yes	Yes	Fillable Fileable
Form	none	180 day follow up survey screenshots	CMEP-RESPECT QDS Screen Shots 180-day Follow-up.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 %

table that charts list of burden
	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

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.