Family Medicine Evaluation

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⚠️ Notice: This information collection may be referencing outdated material.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
Family Medicine Evaluation Form
Family Medicine Evaluation T4 Family Medicine Evaluation Questions Addendum for Practice or Individual Provider.pdf Form
J4 Family Medicine Evaluation Questions Addendum for Practice or Individual Provider.doc Family Medicine Evaluation IC Document

Information Collection (IC) Details

IC Title:	Family Medicine Evaluation	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	Family Medicine Evaluation	T4 Family Medicine Evaluation Questions Addendum for Practice or Individual Provider.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 62	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	62	62
Annual IC Time Burden (Hours)	8	8
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Family Medicine Evaluation	J4 Family Medicine Evaluation Questions Addendum for Practice or Individual Provider.doc	03/02/2016

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