FASD Toolkit User Survey

Improving Fetal Alcohol Spectrum Disorders Prevention and Practice through Practice and Implementation Centers and National Partnerships

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1129 can be found here:

Documents and Forms

Document Name Document Type
FASD Toolkit User Survey Form
FASD Toolkit User Survey FASD Toolkit User Survey.pdf Form
FASD Toolkit User Survey_Edited.docx FASD Toolkit User Survey - word IC Document

Information Collection (IC) Details

IC Title:	FASD Toolkit User Survey	Agency IC Tracking Number:	17ADN

Is this a Common Form? No		IC Status: Modified

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	none	FASD Toolkit User Survey	FASD Toolkit User Survey.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	13	13
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
FASD Toolkit User Survey - word	FASD Toolkit User Survey_Edited.docx	05/09/2017

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