Information Collection

3 & 6 Month Follow-Up Questionnaire - Pilot

IC 221123 under ICR 201603-0920-013 · OMB 0920-1149.

Documents and Forms

Document Name Document Type
3 & 6 Month Follow-Up Questionnaire - Pilot Form
3 and 6 Mopnth Follow-Up Questionnaire for Men Attachment8a-3_3-6 Month follow up Questionnaire - Male.pdf Form
3 and 6 Mopnth Follow-Up Questionnaire for Women Attachment8b-3_3-6 Month follow up Questionnaire- Female.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	3 & 6 Month Follow-Up Questionnaire - Pilot	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	NA	3 and 6 Mopnth Follow-Up Questionnaire for Men	Attachment8a-3_3-6 Month follow up Questionnaire - Male.pdf	NA	No		Paper Only
Form	NA	3 and 6 Mopnth Follow-Up Questionnaire for Women	Attachment8b-3_3-6 Month follow up Questionnaire- Female.pdf	NA	No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	50	50
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.