OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Self-Administered Forms (Mother)

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

Documents and Forms
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Information Collection (IC) Details

View Information Collection (IC)

Self-Administered Forms (Mother) 16PA
 
No Unchanged
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted 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

Health Public Health Monitoring

 

267 0
   
Individuals or Households
 
   0 %

  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 267 0 0 0 0 267
Annual IC Time Burden (Hours) 467 0 0 0 0 467
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.