Cumulative Services Assessment Form

National Center of Excellence for Infant and Early Childhood Mental Health Consultation

Documents and Forms

Document Name Document Type
Form Cumulative Assessm Cumulative Services Assessment Form Form and Instruction
Cumulative Assessm Cumulative Assessment IECMHC_Attachment E_Cumulative Assessment_2-10-16.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Cumulative Services Assessment Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Cumulative Assessment	Cumulative Assessment	IECMHC_Attachment E_Cumulative Assessment_2-10-16.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 17	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	17	17
Annual IC Time Burden (Hours)	6	6
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.