Information Collection

Act Early Parent Intercept Interview

IC 212933 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	Form
Act Early Parent Interview- Word Att 10_Act Early Parent Intercept Interview (Word)_v2_Westat rev.docx	Form
Att 10A_Act Early Parent Intercept Interview_Booklet Version (screenshots)-v2.pdf Parent Interview Booklet Version - Screenshot	IC Document
Att 10B_Act Early Parent Intercept Intrvw_Broc (screenshots)-v2.pdf Parent Interview Brochure Version - Screenshot	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 Interview- Word	Att 10_Act Early Parent Intercept Interview (Word)_v2_Westat rev.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40

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	40	40
Annual IC Time Burden (Hours)	10	10
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Parent Interview Booklet Version - Screenshot	Att 10A_Act Early Parent Intercept Interview_Booklet Version (screenshots)-v2.pdf	09/03/2014
Parent Interview Brochure Version - Screenshot	Att 10B_Act Early Parent Intercept Intrvw_Broc (screenshots)-v2.pdf	09/03/2014

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