Information Collection

Counselor Follow-up Questionnaire

IC 205813 under ICR 201606-0930-003 · OMB 0930-0274.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Counselor Question Counselor Follow-up Questionnaire	Form and Instruction
Counselor Question Counselor Questionnaire Attachment D. Counselor Questionnaire 031616.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	Counselor Questionnaire	Counselor Questionnaire	Attachment D. Counselor Questionnaire 031616.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 42

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	630	-620	1,250
Annual IC Time Burden (Hours)	107	-106	213
Annual IC Cost Burden (Dollars)	0	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.