Information Collection

Pre-Post Feedback Study Cheld Assent Form

IC 217714 under ICR 201511-0925-006 · OMB 0925-0729.

Documents and Forms

Document Name Document Type
Form 6 Pre-Post Feedback Study Cheld Assent Form Form and Instruction
6 Attachment N Pre-Post Feedback Study Child Assent Form Attachment N_Pre-Post Feedback Study Child Assent Form.doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Pre-Post Feedback Study Cheld 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	6	Attachment N Pre-Post Feedback Study Child Assent Form	Attachment N_Pre-Post Feedback Study 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: 34	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	34	34
Annual IC Time Burden (Hours)	3	3
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.