Information Collection

Individual Interview Child Assent Form

IC 217712 under ICR 201511-0925-006 · OMB 0925-0729.

Documents and Forms

Document Name Document Type
Form 4 Individual Interview Child Assent Form Form and Instruction
4 Attachment F Individual Interview Child Assent Form Attachment F_Individual Interview Child Assent Form.doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Individual Interview Child Assent Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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 and Instruction	4	Attachment F Individual Interview Child Assent Form	Attachment F_Individual Interview Child Assent 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 %

	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

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.