Information Collection

Six and Twelve Month Follow-up Questionnaire - for Environment

IC 198574 under ICR 201408-0920-008 · OMB 0920-0906.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0906 Six and Twelve Month Follow-up Questionnaire - for Environment	Form and Instruction
6 and 12 month Follow-up Children Appendix D8 -6 and 12-mo (Children 7-12 years) 7-1-11.doc	Form
0920-0906 Appndx D9_6_12mo_C7-12 7-1-2011 Appndx D9_6_12mo_C7-12 7-1-2011.doc	Form and Instruction
Appendix D8 -6 and 12-mo (Children 7-12 years) 5-10-11_CHN7.31.2011.doc 6 and 12 month - children - Chinese	IC Document
Appendix D8 -6 and 12-mo (Children 7-12 years) 5-10-11 SPANISH.docx 6 and 12 month - children - Spanish	IC Document

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 and Instruction	0920-0906	Appndx D9_6_12mo_C7-12 7-1-2011	Appndx D9_6_12mo_C7-12 7-1-2011.doc		Yes	Yes	Fillable Fileable
Form	none	6 and 12 month Follow-up Children	Appendix D8 -6 and 12-mo (Children 7-12 years) 7-1-11.doc		Yes	No	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title: Epidemiological Studies and Surveillance of Disease Problems 09-20-0136

FR Citation: 57 FR 62812

Number of Respondents: 832

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	Previously Approved
Annual Number of Responses for this IC	1,664	1,664
Annual IC Time Burden (Hours)	277	277
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
6 and 12 month - children - Chinese	Appendix D8 -6 and 12-mo (Children 7-12 years) 5-10-11_CHN7.31.2011.doc	12/14/2011
6 and 12 month - children - Spanish	Appendix D8 -6 and 12-mo (Children 7-12 years) 5-10-11 SPANISH.docx	12/14/2011

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