Information Collection

Assessment and Referral Tool

IC 201610 under ICR 201901-0930-004 · OMB 0930-0270.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0270 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Adult Assessment a Assessment and Referral Tool	Form and Instruction
Adult Assessment a Adult Assessment and Referral Tool Attachment D-AdultAssessmentandReferralTool.pdf	Form and Instruction
Child Assessment a Child Assessment and Referral Tool Attachment E-ChildYouthAssessmentandReferralTool.pdf	Form and Instruction

IC Title:

Assessment and Referral Tool

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 and Instruction	Adult Assessment and Referral Tool	Adult Assessment and Referral Tool	Attachment D-AdultAssessmentandReferralTool.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	Child Assessment and Referral Tool	Child Assessment and Referral Tool	Attachment E-ChildYouthAssessmentandReferralTool.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 600

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5,862	5,862
Annual IC Time Burden (Hours)	1,482	1,482
Annual IC Cost Burden (Dollars)	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.