Information Collection

3- and 6-Month Follow-up

IC 222626 under ICR 201607-0930-002 · OMB 0930-0371.

Documents and Forms

Document Name Document Type
Form 3-Month Follow-up 3- and 6-Month Follow-up Form and Instruction
3-Month Follow-up 3-Month Follow-up Survey 3__Attachment 3 - MHFA follow up survey - 3 or 6 months.pdf Form and Instruction
7__Attachment 7 - MHFA Evaluation consent form for follow-up survey 02 24 16.pdf Follow-up Consent Form IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	3- and 6-Month 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 and Instruction	3-Month Follow-up Survey	3-Month Follow-up Survey	3__Attachment 3 - MHFA follow up survey - 3 or 6 months.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 36,480	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	36,480	36,480
Annual IC Time Burden (Hours)	6,201	6,201
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Follow-up Consent Form	7__Attachment 7 - MHFA Evaluation consent form for follow-up survey 02 24 16.pdf	07/26/2016

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