Information Collection

Self Administered Forms

IC 224189 under ICR 202011-0920-002 · OMB 0920-1171.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1171 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment 8.a. Maternal Medical History _ SEED 3.doc	Other-WORD
Attachment 8.b. Paternal and Occupational Medical History SEED 3.doc	Other-WORD
Attachment 8.c. Child Health History Form SEED 3.docx	Other-WORD
Attachment 8.d. Maternal and Child Residential History Form SEED 3.doc	Other-WORD
Attachment 8.j._Cover letter SEED 3_ DD.docx	Other-WORD
Attachment 8.k. Yellow FolderInstr_Things to keep SEED 3_ASD POP.doc	Instruction
Attachment 8.m. Green Folder Inst_Checklist_Things to return_SEED 3_DD.doc	Instruction
Attachment 8.p. Self Admin Forms Consent SEED 3 ASD, POP, and DD.doc	Other-ord
Attachment 8.o. Medical Glossary for Maternal Paternal and Child Health Forms.doc Att 80_Medical Glossary for Maternal Paternal and Child Health Forms	IC Document

IC Title:

Self Administered Forms

Agency IC Tracking Number:

16 PA

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Electronic Capability
Other-WORD	Attachment 8.a. Maternal Medical History _ SEED 3.doc	No	Fillable Fileable
Other-WORD	Attachment 8.b. Paternal and Occupational Medical History SEED 3.doc	No	Fillable Fileable
Other-WORD	Attachment 8.c. Child Health History Form SEED 3.docx	No	Fillable Fileable
Other-WORD	Attachment 8.d. Maternal and Child Residential History Form SEED 3.doc	No	Fillable Fileable
Other-WORD	Attachment 8.j._Cover letter SEED 3_ DD.docx	No	Paper Only
Instruction	Attachment 8.k. Yellow FolderInstr_Things to keep SEED 3_ASD POP.doc	No	Fillable Fileable
Instruction	Attachment 8.m. Green Folder Inst_Checklist_Things to return_SEED 3_DD.doc	No	Paper Only
Other-ord	Attachment 8.p. Self Admin Forms Consent SEED 3 ASD, POP, and DD.doc	No	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 140

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	140	140
Annual IC Time Burden (Hours)	128	128
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 80_Medical Glossary for Maternal Paternal and Child Health Forms	Attachment 8.o. Medical Glossary for Maternal Paternal and Child Health Forms.doc	10/27/2016

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