Information Collection

BABI 12 - Month Questionnaire

IC 219649 under ICR 201601-0920-012 · OMB 0920-1115.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1115 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-15BEB BABI 12 - Month Questionnaire	Form and Instruction
0920-15BEB Att 5_BABI_12MQuestionnaire_ENG_ Att 5_BABI_12MQuestionnaire_ENG_V1 0_01122016.pdf	Form and Instruction
0920-15BEB Att 5s_BABI_12MQuestionnaire_SPAN Att 5s_BABI_12MQuestionnaire_SPAN_V1 0_01122016.pdf	Form and Instruction

IC Title:

BABI 12 - Month Questionnaire

Agency IC Tracking Number:

0920-15BEB

Is this a Common Form? No

IC Status: New

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	0920-15BEB	Att 5_BABI_12MQuestionnaire_ENG_	Att 5_BABI_12MQuestionnaire_ENG_V1 0_01122016.pdf		No		Fillable Printable
Form and Instruction	0920-15BEB	Att 5s_BABI_12MQuestionnaire_SPAN	Att 5s_BABI_12MQuestionnaire_SPAN_V1 0_01122016.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 57

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	57	57
Annual IC Time Burden (Hours)	13	13
Annual IC Cost Burden (Dollars)	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.