DSW Report

Improving Fetal Alcohol Spectrum Disorders Prevention and Practice through Practice and Implementation Centers and National Partnerships

Documents and Forms

Document Name Document Type
DSW Report Form
DSW Report O1 DSW Report Screenshot.docx Form
DSW Report O1 DSW Report Screenshot.docx Form
E1 DSW Report.docx DSW Report - word IC Document
E1 DSW Report.docx DSW Report - word IC Document

Information Collection (IC) Details

IC Title:	DSW Report	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

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	none	DSW Report	O1 DSW Report Screenshot.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 90	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	-180	180
Annual IC Time Burden (Hours)	-30	30
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
DSW Report - word	E1 DSW Report.docx	03/02/2016

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