Information Collection

BABI 12 - Month Questionnaire

IC 219649 under ICR 201711-0920-001 · OMB 0920-1115.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1115 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
BABI 12 - Month Questionnaire	Form and Instruction
12-month Questionnaire for Control Group (English) Attachment 5-C_BABI_12MQuestionnaire_ENG_V1.0.pdf	Form and Instruction
12-month Questionnaire for Intervention Group (English) Attachment 5-I_BABI_12MQuestionnaire_ENG_V1.0.pdf	Form and Instruction
12-month Questionnaire for Control Group (Spanish) Attachment 5s-C_BABI_12MQuestionnaire_SPAN_V1.0.pdf	Form and Instruction
12-month Questionnaire for Intervention Group (Spanish) Attachment 5s-I_BABI_12MQuestionnaire_SPAN_V1.0.pdf	Form and Instruction

IC Title:

BABI 12 - Month Questionnaire

Agency IC Tracking Number:

0920-15BEB

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	n/a	12-month Questionnaire for Control Group (English)	Attachment 5-C_BABI_12MQuestionnaire_ENG_V1.0.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	12-month Questionnaire for Intervention Group (English)	Attachment 5-I_BABI_12MQuestionnaire_ENG_V1.0.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	12-month Questionnaire for Control Group (Spanish)	Attachment 5s-C_BABI_12MQuestionnaire_SPAN_V1.0.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	12-month Questionnaire for Intervention Group (Spanish)	Attachment 5s-I_BABI_12MQuestionnaire_SPAN_V1.0.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 57

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	57	0	57
Annual IC Time Burden (Hours)	15	2	13
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.