Information Collection

Child Behavior Checklist (for Covid-19 Impact Assessment)

IC 244362 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Child Behavior Checklist (for Covid-19 Impact Assessment) Form and Instruction
Child Behavior Checklist for Ages 1 1/2 - 5 Years ITEM #3 Appendix C.1_COV-IMP_CBCL_1-5yrs.pdf Form and Instruction
Child Behavior Checklist for Ages 6-18 ITEM #4 Appendix C.2_COV-IMP_CBCL_school age.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Child Behavior Checklist (for Covid-19 Impact Assessment)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	n/a	Child Behavior Checklist for Ages 1 1/2 - 5 Years	ITEM #3 Appendix C.1_COV-IMP_CBCL_1-5yrs.pdf		No		Paper Only
Form and Instruction	n/a	Child Behavior Checklist for Ages 6-18	ITEM #4 Appendix C.2_COV-IMP_CBCL_school age.pdf		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-20-1036, Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 81 FR 9200

Number of Respondents: 1,330	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
Annual Number of Responses for this IC	1,330	1,330
Annual IC Time Burden (Hours)	443	443
Annual IC Cost Burden (Dollars)	11,398	11,398

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.