Information Collection

Clicnic/Home Visit - Developmental Assessment (Mother)

IC 224165 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Attachment 11.c. Overall Consent _POP SEED 3_revised.doc 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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Clicnic/Home Visit - Developmental Assessment (Mother)	Agency IC Tracking Number:	16PA

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Electronic Capability
Other-WORD	Attachment 11.c. Overall Consent _POP SEED 3_revised.doc	No	Fillable Fileable Signable
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
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:	FR Citation:

Number of Respondents: 234	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	234	234
Annual IC Time Burden (Hours)	195	195
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.