Information Collection

Client questionnaire - 12 month follow-up

IC 228978 under ICR 202012-0920-014 · OMB 0920-1218.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Client questionnaire - 12 month follow-up	Form
Client questionnaire - 12 month follow up - Spanish Attachment 6 Client Questionnaire baseline 12 24 months__09_27_17_spanish.docx	Form
Client questionnaire - 12 month follow up - Spanish Attachment 6 Client Questionnaire baseline 12 24 months__09_27_17_spanish.docx	Form
Client questionnaire - 12 month follow-up - English Attachment 6 Client Questionnaire baseline 12 24 months_9_27_17 17ACE_MAT.docx	Form
Client questionnaire - 12 month follow-up - English Attachment 6 Client Questionnaire baseline 12 24 months_9_27_17 17ACE_MAT.docx	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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	none	Client questionnaire - 12 month follow up - Spanish	Attachment 6 Client Questionnaire baseline 12 24 months__09_27_17_spanish.docx		Yes	Yes	Fillable Fileable
Form	none	Client questionnaire - 12 month follow-up - English	Attachment 6 Client Questionnaire baseline 12 24 months_9_27_17 17ACE_MAT.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 930

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	-930	930
Annual IC Time Burden (Hours)	-698	698
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.