Information Collection

Clinic / Home Visit - Saliva Collection (Mother)

IC 224017 under ICR 201610-0920-010 · OMB 0920-1171.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1171 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment 11.a. Overall Consent _ASD SEED 3_revised.doc	Other-WORD
Attachment 9.b. Vineland Scoresheet SEED 3.pdf	Other-WORD
Attachment 9.c. Vineland Script SEED 3.doc	Other-WORD
Attachment 9.g. ADI-R Score Sheet.pdf	Other-WORD
Attachment 16.a. Anthropometric Exam Form SEED 3_tmj8-25-17.doc	Other-WOrd
Attachment 16.b. Saliva Collection Instructions Form SEED 3.docx	Instruction
Attachment 16.c. Saliva Consent Form SEED 3.docx	Other-WORD
Attachment 16.d. Saliva Transmittal Form SEED 3_tmj8-25-17.doc	Other-WORD
Attachment 17.b. Adult Blood Draw Form SEED 3_tmj8-25-17.doc	Other-WORD
Attachment 9.g. CoverSheet_ADI-R Score Sheet.pdf.doc Att 9g_CoverSheet	IC Document

IC Title:

Clinic / Home Visit - Saliva Collection (Mother)

Agency IC Tracking Number:

16PA

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	Instrument File	Available Electronically?	Electronic Capability
Other-WORD	Attachment 11.a. Overall Consent _ASD SEED 3_revised.doc	No	Fillable Fileable Signable
Other-WORD	Attachment 9.b. Vineland Scoresheet SEED 3.pdf	No	Fillable Fileable
Other-WORD	Attachment 9.c. Vineland Script SEED 3.doc	No	Paper Only
Other-WORD	Attachment 9.g. ADI-R Score Sheet.pdf	No	Fillable Fileable
Other-WOrd	Attachment 16.a. Anthropometric Exam Form SEED 3_tmj8-25-17.doc	No	Fillable Fileable
Instruction	Attachment 16.b. Saliva Collection Instructions Form SEED 3.docx	No	Paper Only
Other-WORD	Attachment 16.c. Saliva Consent Form SEED 3.docx	No	Fillable Fileable Signable
Other-WORD	Attachment 16.d. Saliva Transmittal Form SEED 3_tmj8-25-17.doc	No	Fillable Fileable
Other-WORD	Attachment 17.b. Adult Blood Draw Form SEED 3_tmj8-25-17.doc	No	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0136: Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 328

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	328	328
Annual IC Time Burden (Hours)	1,230	1,230
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 9g_CoverSheet	Attachment 9.g. CoverSheet_ADI-R Score Sheet.pdf.doc	10/19/2016

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