Information Collection

Self-Administered Forms (Mother)

IC 224163 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⚠️ Notice: This information collection may be referencing outdated material.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 8.a. Maternal Medical History _ SEED 3.doc	Other-WORD
Attachment 8.b. Paternal and Occupational Medical History SEED 3.doc	Other-WORD
Attachment 8.c. Child Health History Form SEED 3.docx	Other-WORD
Attachment 8.d. Maternal and Child Residential History Form SEED 3.doc	Other-WORD
Attachment 8.e. Child Behavior Check List (CBCL) SEED 3.pdf	Other-WORD
Attachment 8.f. Social Responsiveness Scale (Preschool).pdf	Other-WORD
Attachment 8.g. Social Responsiveness Scale (Child).pdf	Other-WORD
Attachment 8.h. Services and Treatments Questionnaire SEED 3.docx	Other-WORD
Attachment 8.p. Self Admin Forms Consent SEED 3 ASD, POP, and DD.doc	Other-WPRD
Attachment 8.e. CoverSheet_Child Behavior Check List (CBCL) SEED 3..doc Att 8e_Cover Sheet	IC Document
Attachment 8.i._Cover letter SEED 3_ ASD POP.docx Att 8i_Cover Letter ASD and POP	IC Document
Attachment 8.k. Yellow FolderInstr_Things to keep SEED 3_ASD POP.doc Att 8k _ Instructions Yellow Folder	IC Document
Attachment 8.n. Green Folder Inst_Checklist_Things to return_SEED 3_POP.doc Att 8n _ Instructions and Check List Green Folder (POP)	IC Document
Attachment 8.o. Medical Glossary for Maternal Paternal and Child Health Forms.doc Att 8o _ Medical Glossary	IC Document

IC Title:

Self-Administered Forms (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	Available Electronically?	Electronic Capability
Other-WORD	No	Fillable Printable
Other-WORD	No	Fillable Printable
Other-WORD	No	Fillable Printable
Other-WORD	No	Fillable Printable
Other-WORD	No	Fillable Printable
Other-WORD	No	Fillable Printable
Other-WORD	No	Fillable Printable
Other-WORD	No	Fillable Printable
Other-WPRD	No	Fillable Fileable Signable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 267

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	267	267
Annual IC Time Burden (Hours)	467	467
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 8e_Cover Sheet		10/26/2016
Att 8i_Cover Letter ASD and POP		10/26/2016
Att 8k _ Instructions Yellow Folder		10/26/2016
Att 8n _ Instructions and Check List Green Folder (POP)		10/26/2016
Att 8o _ Medical Glossary		10/26/2016

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

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