Information Collection

Adult Follow-up - Screenshot

IC 209242 under ICR 201502-0925-002 · OMB 0925-0685.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 5 Adult Follow-up Adult Follow-up - Screenshot	Form
5 Adult Follow-up Attachment 22 - Screenshot Adult Followup - MDF.zip	Form
Attachment_5_-_Data_collection_instrument_-_Adult_questionnaire_Followup_MDF[1].pdf Adult Follow-up	IC Document

IC Title:

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
Form	5				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: SORN 09-25-0200

FR Citation: 67 FR 60741

Number of Respondents: 200

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	150	150
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Adult Follow-up		11/06/2013

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

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