Act Early Parent Intercept Interview Screener

Testing Act Early Messages and Materials for "Learn the Signs. Act Early" - Phase II

Documents and Forms

Document Name Document Type
Act Early Parent Intercept Interview Screener Form
Act Early Parent Intercept Interview Screener Screenshot Att 9A_Act Early Parent Intercept Interview Screener (screenshots)-v2_Westat rev 082614.pdf Form
Att 9_Act Early Parent Intercept Interview Screener_Westat rev.docx Interview Screener - Word IC Document

Information Collection (IC) Details

IC Title:	Act Early Parent Intercept Interview Screener	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	Act Early Parent Intercept Interview Screener Screenshot	Att 9A_Act Early Parent Intercept Interview Screener (screenshots)-v2_Westat rev 082614.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 80	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	80	80
Annual IC Time Burden (Hours)	7	7
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Interview Screener - Word	Att 9_Act Early Parent Intercept Interview Screener_Westat rev.docx	09/03/2014

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