Information Collection

Client questionnaire - 18 month follow-up

IC 228979 under ICR 202012-0920-014 · OMB 0920-1218.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Client questionnaire - 18 month follow-up	Form
Client questionnaire - 18 month follow-up Attachment 4 Client Questionnaire baseline 12 18 months_12.21.2020.docx	Form
Client questionnaire - 18 month follow-up Attachment 4 Client Questionnaire baseline 12 18 months_12.21.2020.docx	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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 - 18 month follow-up	Attachment 4 Client Questionnaire baseline 12 18 months_12.21.2020.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: 400

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	400	-344	744
Annual IC Time Burden (Hours)	300	-258	558
Annual IC Cost Burden (Dollars)	0	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.