Information Collection

BABI 12 - Month Questionnaire

IC 219649 under ICR 201805-0920-009 · OMB 0920-1115.

Documents and Forms

Document Name Document Type
BABI 12 - Month Questionnaire Form and Instruction
12 month quesionnaire -Control - English Attachment 5-C_BABI_12MQuestionnaire_ENG_V1.0.pdf Form and Instruction
12 month questionnaire - Intervention - English Attachment 5-I_BABI_12MQuestionnaire_ENG_V1.0.pdf Form and Instruction
12 month questionnaire - Control - Spanish Attachment 5s-C_BABI_12MQuestionnaire_SPAN_V1.0.pdf Form and Instruction
12 month questionnaire - Intervention - Spanish Attachment 5s-I_BABI_12MQuestionnaire_SPAN_V1.0.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

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:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	none	12 month quesionnaire -Control - English	Attachment 5-C_BABI_12MQuestionnaire_ENG_V1.0.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	none	12 month questionnaire - Intervention - English	Attachment 5-I_BABI_12MQuestionnaire_ENG_V1.0.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	none	12 month questionnaire - Control - Spanish	Attachment 5s-C_BABI_12MQuestionnaire_SPAN_V1.0.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	none	12 month questionnaire - Intervention - 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: 52	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	52	-5	57
Annual IC Time Burden (Hours)	14	-1	15
Annual IC Cost Burden (Dollars)	0	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.