OBGYN Provider Follow-up

Improving Fetal Alcohol Spectrum Disorders Prevention and Practice through Practice and Implementation Centers and National Partnerships

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1129 can be found here:

Documents and Forms

Document Name Document Type
OBGYN Provider Follow-up Form
OBGYN Provider Follow-up R4 OBGYN BI-MI Proficiency Rating Scale_Provider Follow Up (3m and 6m).pdf Form
H4 OBGYN BI-MI Proficiency Rating Scale - Provider Follow Up (3m & 6m).docx OBGYN Provider Follow-up - word IC Document

Information Collection (IC) Details

IC Title:	OBGYN Provider Follow-up	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	none	OBGYN Provider Follow-up	R4 OBGYN BI-MI Proficiency Rating Scale_Provider Follow Up (3m and 6m).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 600	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	1,200	1,200
Annual IC Time Burden (Hours)	60	60
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
OBGYN Provider Follow-up - word	H4 OBGYN BI-MI Proficiency Rating Scale - Provider Follow Up (3m & 6m).docx	03/02/2016

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