Act Early Parent Intercept Interview

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 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

Information Collection (IC) Details

IC Title:	Act Early Parent Intercept Interview	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 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 %

	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

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.