Information Collection

36-month Adult Follow-up Survey

IC 209542 under ICR 201609-2528-001 · OMB 2528-0259.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2528-0259 can be found here:

Documents and Forms

Document Name Document Type
Appendix B_36-Month Followup ADULT Survey.docx Other-Adult Survey
Adult Consent Form Appendix A1_ 36-month consent_Adult Respondents_1_13.docx Form
Release of Information Appendix A4_Release of Information_1_8.docx Form
Parental Permission form Appendix A2_ Parental Permission Form_1_13.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	36-month Adult Follow-up Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Other-Adult Survey			Appendix B_36-Month Followup ADULT Survey.docx	No	Paper Only
Form	N/A	Adult Consent Form	Appendix A1_ 36-month consent_Adult Respondents_1_13.docx	No	Paper Only
Form	N/A	Release of Information	Appendix A4_Release of Information_1_8.docx	No	Paper Only
Form	N/A	Parental Permission form	Appendix A2_ Parental Permission Form_1_13.docx	No	Paper Only

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,712	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-1,712	1,712
Annual IC Time Burden (Hours)	-2,140	2,140
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.