Information Collection

Self Administered Forms (Mother)

IC 224015 under ICR 202011-0920-014 · 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⚠️ Notice: This information collection may be referencing outdated material.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.e. Child Behavior Check List (CBCL) SEED 3.pdf	Other-WORD
Attachment 8.f. Social Responsiveness Scale (Preschool).pdf	Other-WORD
Attachment 8.g. Social Responsiveness Scale (Child).pdf	Other-WORD
Attachment 8.h. Services and Treatments Questionnaire SEED 3.docx	Other-WORD
Attachment 8.k. Yellow FolderInstr_Things to keep SEED 3_ASD POP.doc	Other-WORD
Attachment 8.i._Cover letter SEED 3_ ASD POP.docx	Other-WORD
Attachment 8.l. Green Folder Inst_Checklist_Things to return_SEED 3_ASD.doc	Other-WORD
Attachment 8.o. Medical Glossary for Maternal Paternal and Child Health Forms.doc	Other-WORD
Attachment 8.p. Self Admin Forms Consent SEED 3 ASD, POP, and DD.doc	Other-WORD
Attachment 8.e. CoverSheet_Child Behavior Check List (CBCL) SEED 3..doc Att 8e_CoverSheet	IC Document
Attachment 8.f. CoverSheet_Social Responsiveness Scale (Preschool).doc Att 8f_Coversheet	IC Document
Attachment 8.g. CoverSheet_Social Responsiveness Scale (Child).doc Att 8g_CoverSheet	IC Document

IC Title:

Self Administered Forms (Mother)

Agency IC Tracking Number:

16PA

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 Printable
Other-WORD	Attachment 8.b. Paternal and Occupational Medical History SEED 3.doc	No	Fillable Printable
Other-WORD	Attachment 8.c. Child Health History Form SEED 3.docx	No	Fillable Printable
Other-WORD	Attachment 8.d. Maternal and Child Residential History Form SEED 3.doc	No	Fillable Printable
Other-WORD	Attachment 8.e. Child Behavior Check List (CBCL) SEED 3.pdf	No	Fillable Printable
Other-WORD	Attachment 8.f. Social Responsiveness Scale (Preschool).pdf	No	Fillable Printable
Other-WORD	Attachment 8.g. Social Responsiveness Scale (Child).pdf	No	Fillable Printable
Other-WORD	Attachment 8.h. Services and Treatments Questionnaire SEED 3.docx	No	Fillable Printable
Other-WORD	Attachment 8.k. Yellow FolderInstr_Things to keep SEED 3_ASD POP.doc	No	Fillable Printable
Other-WORD	Attachment 8.i._Cover letter SEED 3_ ASD POP.docx	No	Paper Only
Other-WORD	Attachment 8.l. Green Folder Inst_Checklist_Things to return_SEED 3_ASD.doc	No	Paper Only
Other-WORD	Attachment 8.o. Medical Glossary for Maternal Paternal and Child Health Forms.doc	No	Fillable Fileable
Other-WORD	Attachment 8.p. Self Admin Forms Consent SEED 3 ASD, POP, and DD.doc	No	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: 09-20-0136: Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 375

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	375	375
Annual IC Time Burden (Hours)	656	656
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 8e_CoverSheet	Attachment 8.e. CoverSheet_Child Behavior Check List (CBCL) SEED 3..doc	10/19/2016
Att 8f_Coversheet	Attachment 8.f. CoverSheet_Social Responsiveness Scale (Preschool).doc	10/19/2016
Att 8g_CoverSheet	Attachment 8.g. CoverSheet_Social Responsiveness Scale (Child).doc	10/19/2016

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