Family Medicine Evaluation

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

OMB: 0920-1129

IC ID: 220422

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Family Medicine Evaluation
 
No Removed
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form none Family Medicine Evaluation T4 Family Medicine Evaluation Questions Addendum for Practice or Individual Provider.pdf Yes Yes Fillable Fileable

Health Public Health Monitoring

 

62 0
   
Individuals or Households
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 0 0 0 -62 62 0
Annual IC Time Burden (Hours) 0 0 0 -8 8 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Family Medicine Evaluation J4 Family Medicine Evaluation Questions Addendum for Practice or Individual Provider.doc 03/02/2016
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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