Information Collection

Clinic / Home Visit -Development Assessment (Child)

IC 224019 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⚠️ Notice: This information collection may be referencing outdated material.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 9.a. Mullenscoresheet SEED 3.pdf	Other-WORD
Attachment 9.d. ADOS-2 Score Sheet Module-1 SEED-3.pdf	Other-WORD
Attachment 9.e. ADOS-2 Score Sheet Module-2 SEED-3.pdf	Other-WORD
Attachment 9.f. ADOS-2 Score Sheet Module-3 SEED-3.pdf	Other-WORD
Attachment 16.a. Anthropometric Exam Form SEED 3_tmj8-25-17.doc	Other-WORD
Attachment 16.b. Saliva Collection Instructions Form SEED 3.docx	Instruction
Attachment 16.c. Saliva Consent Form SEED 3.docx	Other-WORD
Attachment 16.d. Saliva Transmittal Form SEED 3_tmj8-25-17.doc	Other-WORD
Attachment 17.a .Child Blood Draw Form SEED 3_tmj8-25-17.doc	Other-WORD
Attachment 9.d. CoverSheet_ADOS-2 Score Sheet Module-1 SEED-3.pdf.doc Att 9d_CoverSheet	IC Document
Attachment 9.e. CoverSheet_ADOS-2 Score Sheet Module-2 SEED-3.pdf.doc Att 9e_CoverSheet	IC Document
Attachment 9.f. CoverSheet_ADOS-2 Score Sheet Module-3 SEED-3.pdf.doc Att 9f_CoverSheet	IC Document

IC Title:

Clinic / Home Visit -Development Assessment (Child)

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 9.a. Mullenscoresheet SEED 3.pdf	No	Fillable Fileable
Other-WORD	Attachment 9.d. ADOS-2 Score Sheet Module-1 SEED-3.pdf	No	Fillable Fileable
Other-WORD	Attachment 9.e. ADOS-2 Score Sheet Module-2 SEED-3.pdf	No	Fillable Fileable
Other-WORD	Attachment 9.f. ADOS-2 Score Sheet Module-3 SEED-3.pdf	No	Fillable Fileable
Other-WORD	Attachment 16.a. Anthropometric Exam Form SEED 3_tmj8-25-17.doc	No	Fillable Fileable
Instruction	Attachment 16.b. Saliva Collection Instructions Form SEED 3.docx	No	Paper Only
Other-WORD	Attachment 16.c. Saliva Consent Form SEED 3.docx	No	Fillable Fileable Signable
Other-WORD	Attachment 16.d. Saliva Transmittal Form SEED 3_tmj8-25-17.doc	No	Fillable Fileable
Other-WORD	Attachment 17.a .Child Blood Draw Form SEED 3_tmj8-25-17.doc	No	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

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

FR Citation: 57 FR 62812

Number of Respondents: 328

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	328	328
Annual IC Time Burden (Hours)	738	738
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 9d_CoverSheet	Attachment 9.d. CoverSheet_ADOS-2 Score Sheet Module-1 SEED-3.pdf.doc	10/19/2016
Att 9e_CoverSheet	Attachment 9.e. CoverSheet_ADOS-2 Score Sheet Module-2 SEED-3.pdf.doc	10/19/2016
Att 9f_CoverSheet	Attachment 9.f. CoverSheet_ADOS-2 Score Sheet Module-3 SEED-3.pdf.doc	10/19/2016

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