Information Collection

Individual Interview Parent Permission Form

IC 217709 under ICR 201511-0925-006 · OMB 0925-0729.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Individual Interview Parent Permission Form	Form and Instruction
1 Attachment E Individual Interview Parent Permission Form Attachment E_Individual Interview Parent Permission Form.doc	Form and Instruction
Attachment A_Individual Interview Flyer.pdf Attachment A Individual Interview Flyer	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 and Instruction	1	Attachment E Individual Interview Parent Permission Form	Attachment E_Individual Interview Parent Permission Form.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 9

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	9	9
Annual IC Time Burden (Hours)	1	1
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment A Individual Interview Flyer	Attachment A_Individual Interview Flyer.pdf	07/30/2015

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