Information Collection

FASD Toolkit User Survey

IC 220417 under ICR 202102-0920-003 · OMB 0920-1129.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
FASD Toolkit User Survey	Form
FASD Toolkit User Survey FASD Toolkit User Survey	Form
FASD Toolkit User Survey FASD Toolkit User Survey.pdf	Form
FASD Toolkit User Survey FASD Toolkit User Survey.pdf	Form
FASD Toolkit User Survey_Edited.docx FASD Toolkit User Survey - word	IC Document
FASD Toolkit User Survey_Edited.docx FASD Toolkit User Survey - word	IC Document

IC Title:

Agency IC Tracking Number:

17ADN

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	FASD Toolkit User Survey	FASD Toolkit User Survey.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

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	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	-50	50
Annual IC Time Burden (Hours)	-13	13
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
FASD Toolkit User Survey - word	FASD Toolkit User Survey_Edited.docx	05/09/2017

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