Information Collection

Client-Level

IC 46632 under ICR 201512-0930-002 · OMB 0930-0285.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0285 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Child Measures Client-Level	Form and Instruction
Child Measures Child Measures SVCS_ChildCombinedTool_11.19.13.docx	Form and Instruction
Adult Measures Adult Measures SVCS_AdultTool_11.19.13.docx	Form and Instruction

IC Title:

Client-Level

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	Child Measures	Child Measures	SVCS_ChildCombinedTool_11.19.13.docx		Yes	Yes	Paper Only
Form and Instruction	Adult Measures	Adult Measures	SVCS_AdultTool_11.19.13.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 35,845

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	98,148	82,467	15,681
Annual IC Time Burden (Hours)	33,959	19,733	14,226
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.