Information Collection

Self-Administered Forms (Mother)

IC 224163 under ICR 202102-0920-008 · OMB 0920-1171.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment 8.a. Maternal Medical History _ SEED 3.doc	Other-WORD
Attachment 8.a. Maternal Medical History _ SEED 3.doc	Other-WORD
Attachment 8.b. Paternal and Occupational Medical History SEED 3.doc	Other-WORD
Attachment 8.b. Paternal and Occupational Medical History SEED 3.doc	Other-WORD
Attachment 8.c. Child Health History Form SEED 3.docx	Other-WORD
Attachment 8.c. Child Health History Form SEED 3.docx	Other-WORD
Attachment 8.d. Maternal and Child Residential History Form SEED 3.doc	Other-WORD
Attachment 8.d. Maternal and Child Residential History Form SEED 3.doc	Other-WORD
Attachment 8.e. Child Behavior Check List (CBCL) SEED 3.pdf	Other-WORD
Attachment 8.e. Child Behavior Check List (CBCL) SEED 3.pdf	Other-WORD
Attachment 8.f. Social Responsiveness Scale (Preschool).pdf	Other-WORD
Attachment 8.f. Social Responsiveness Scale (Preschool).pdf	Other-WORD
Attachment 8.g. Social Responsiveness Scale (Child).pdf	Other-WORD
Attachment 8.g. Social Responsiveness Scale (Child).pdf	Other-WORD
Attachment 8.h. Services and Treatments Questionnaire SEED 3.docx	Other-WORD
Attachment 8.h. Services and Treatments Questionnaire SEED 3.docx	Other-WORD
Attachment 8.p. Self Admin Forms Consent SEED 3 ASD, POP, and DD.doc	Other-WPRD
Attachment 8.p. Self Admin Forms Consent SEED 3 ASD, POP, and DD.doc	Other-WPRD
Attachment 8.e. CoverSheet_Child Behavior Check List (CBCL) SEED 3..doc Att 8e_Cover Sheet	IC Document
Attachment 8.e. CoverSheet_Child Behavior Check List (CBCL) SEED 3..doc Att 8e_Cover Sheet	IC Document
Attachment 8.i._Cover letter SEED 3_ ASD POP.docx Att 8i_Cover Letter ASD and POP	IC Document
Attachment 8.i._Cover letter SEED 3_ ASD POP.docx Att 8i_Cover Letter ASD and POP	IC Document
Attachment 8.k. Yellow FolderInstr_Things to keep SEED 3_ASD POP.doc Att 8k _ Instructions Yellow Folder	IC Document
Attachment 8.k. Yellow FolderInstr_Things to keep SEED 3_ASD POP.doc Att 8k _ Instructions Yellow Folder	IC Document
Attachment 8.n. Green Folder Inst_Checklist_Things to return_SEED 3_POP.doc Att 8n _ Instructions and Check List Green Folder (POP)	IC Document
Attachment 8.n. Green Folder Inst_Checklist_Things to return_SEED 3_POP.doc Att 8n _ Instructions and Check List Green Folder (POP)	IC Document
Attachment 8.o. Medical Glossary for Maternal Paternal and Child Health Forms.doc Att 8o _ Medical Glossary	IC Document
Attachment 8.o. Medical Glossary for Maternal Paternal and Child Health Forms.doc Att 8o _ Medical Glossary	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Self-Administered Forms (Mother)

Agency IC Tracking Number:

16PA

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Electronic Capability
Other-WORD	Attachment 8.a. Maternal Medical History _ SEED 3.doc	No	Fillable Printable
Other-WORD	Attachment 8.b. Paternal and Occupational Medical History SEED 3.doc	No	Fillable Printable
Other-WORD	Attachment 8.c. Child Health History Form SEED 3.docx	No	Fillable Printable
Other-WORD	Attachment 8.d. Maternal and Child Residential History Form SEED 3.doc	No	Fillable Printable
Other-WORD	Attachment 8.e. Child Behavior Check List (CBCL) SEED 3.pdf	No	Fillable Printable
Other-WORD	Attachment 8.f. Social Responsiveness Scale (Preschool).pdf	No	Fillable Printable
Other-WORD	Attachment 8.g. Social Responsiveness Scale (Child).pdf	No	Fillable Printable
Other-WORD	Attachment 8.h. Services and Treatments Questionnaire SEED 3.docx	No	Fillable Printable
Other-WPRD	Attachment 8.p. Self Admin Forms Consent SEED 3 ASD, POP, and DD.doc	No	Fillable Fileable Signable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 267

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	267	267
Annual IC Time Burden (Hours)	467	467
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 8e_Cover Sheet	Attachment 8.e. CoverSheet_Child Behavior Check List (CBCL) SEED 3..doc	10/26/2016
Att 8i_Cover Letter ASD and POP	Attachment 8.i._Cover letter SEED 3_ ASD POP.docx	10/26/2016
Att 8k _ Instructions Yellow Folder	Attachment 8.k. Yellow FolderInstr_Things to keep SEED 3_ASD POP.doc	10/26/2016
Att 8n _ Instructions and Check List Green Folder (POP)	Attachment 8.n. Green Folder Inst_Checklist_Things to return_SEED 3_POP.doc	10/26/2016
Att 8o _ Medical Glossary	Attachment 8.o. Medical Glossary for Maternal Paternal and Child Health Forms.doc	10/26/2016

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