Information Collection

Act Early Parent Intercept Interview Screener

IC 212932 under ICR 201409-0920-002 · OMB 0920-1041.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.