Information Collection

3 & 6 Month Follow-Up Questionnaire - Pilot

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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

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	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 %

table that charts list of burden
	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

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.