Information Collection

Child Followup- Screenshot

IC 209246 under ICR 201502-0925-002 · OMB 0925-0685.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 12 Child Followup Child Followup- Screenshot	Form
12 Child Followup Attachment 28 - Screenshot Child Followup - MDF.zip	Form
Attachment_11_-_Data_collection_instrument_-_Child_questionnaire_Followup_MDF[1].pdf Child 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	12				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: SORN 02-25-0200

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
Child 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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