Information Collection

3- and 6-Month Follow-up

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

Documents and Forms

Documents and forms in this information collection
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

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 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 %

table that charts list of burden
	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

table that charts IC Documents
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.