Information Collection

BABI 12 - Month Questionnaire

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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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	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 %

table that charts list of burden
	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

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.