Information Collection

Individual Interviews with Parents and Caregivers

IC 225439 under ICR 201701-0930-004 · OMB 0930-0373.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0373 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Parent & Caregiver Individual Interviews with Parents and Caregivers	Form and Instruction
Parent & Caregiver Parent & Caregiver Interview Guide 6_Parent & Caregiver Interview Guide_January 20 2017.docx	Form and Instruction
5_Teacher Script for Youth Survey_January 20 2017.docx Teacher Script for Youth Survey	IC Document
7_Consent Form_Parent caregiver Interviews Consent Form_January 20 2017.docx Consent Form_Parent caregiver Interviews Consent Form	IC Document

IC Title:

Individual Interviews with Parents and Caregivers

Agency IC Tracking Number:

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	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Parent & Caregiver Interview Guide	Parent & Caregiver Interview Guide	6_Parent & Caregiver Interview Guide_January 20 2017.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 30

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	30	30
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Teacher Script for Youth Survey	5_Teacher Script for Youth Survey_January 20 2017.docx	01/30/2017
Consent Form_Parent caregiver Interviews Consent Form	7_Consent Form_Parent caregiver Interviews Consent Form_January 20 2017.docx	01/30/2017

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