Information Collection

3-Month Follow-up Assessment

IC 212286 under ICR 201410-0990-001 · OMB 0990-0422.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0422 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
0990-IPV_Follow-up Assessment_6_26_2014.doc	Other-survey

IC Title:

3-Month Follow-up Assessment

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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
Other-survey			0990-IPV_Follow-up Assessment_6_26_2014.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,600

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	1,600	1,600
Annual IC Time Burden (Hours)	667	667
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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