Information Collection

Parent-Child Eligibility Questionnaire

IC 229191 under ICR 201803-0920-014 · OMB 0920-1190.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Parent-Child Eligibility Questionnaire	Form
Parent Child Follow-up Eligibility Form Att B8_Parent_Child_Follow-up_Eligibility_Screening_Form_13FEB2018_clean.docx	Form
Parent Child Follow-up Eligibility Form - Spanish Att C8_Elegibilidad_padre-nino_seguimiento_13FEB2018_clean.docx	Form
Att B8_Parent_Child_Follow-up_Eligibility_Screening_Form_13FEB2018_track.docx Parent child Followup Eligibility Form - trkchg	IC Document
Att C8_Elegibilidad_padre-nino_seguimiento_13FEB2018_track.docx Parent child Followup Eligibility Form - Spanish - trkchg	IC Document

IC Title:

Agency IC Tracking Number:

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Parent Child Follow-up Eligibility Form	Att B8_Parent_Child_Follow-up_Eligibility_Screening_Form_13FEB2018_clean.docx		No		Paper Only
Form	none	Parent Child Follow-up Eligibility Form - Spanish	Att C8_Elegibilidad_padre-nino_seguimiento_13FEB2018_clean.docx		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0113 - Epidemic Investigation Case Records System

FR Citation: 51 FR 42466

Number of Respondents: 1,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	83	83
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Parent child Followup Eligibility Form - trkchg	Att B8_Parent_Child_Follow-up_Eligibility_Screening_Form_13FEB2018_track.docx	03/26/2018
Parent child Followup Eligibility Form - Spanish - trkchg	Att C8_Elegibilidad_padre-nino_seguimiento_13FEB2018_track.docx	03/26/2018

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