Information Collection

Clinic/Home Visit - Developmental Assessment (Child)

IC 224167 under ICR 202102-0920-008 · OMB 0920-1171.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment 9.a. Mullenscoresheet SEED 3.pdf	Other-WORD
Attachment 9.a. Mullenscoresheet SEED 3.pdf	Other-WORD
Attachment 16.a. Anthropometric Exam Form SEED 3_tmj8-25-17.doc	Other-WORD
Attachment 16.a. Anthropometric Exam Form SEED 3_tmj8-25-17.doc	Other-WORD
Attachment 16.b. Saliva Collection Instructions Form SEED 3.docx	Instruction
Attachment 16.b. Saliva Collection Instructions Form SEED 3.docx	Instruction
Attachment 16.c. Saliva Consent Form SEED 3.docx	Other-WORD
Attachment 16.c. Saliva Consent Form SEED 3.docx	Other-WORD
Attachment 16.d. Saliva Transmittal Form SEED 3_tmj8-25-17.doc	Other-WORD
Attachment 16.d. Saliva Transmittal Form SEED 3_tmj8-25-17.doc	Other-WORD
Attachment 17.b. Adult Blood Draw Form SEED 3_tmj8-25-17.doc	Other-WORD
Attachment 17.b. Adult Blood Draw Form SEED 3_tmj8-25-17.doc	Other-WORD

IC Title:

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 9.a. Mullenscoresheet SEED 3.pdf	No	Fillable Fileable
Other-WORD	Attachment 16.a. Anthropometric Exam Form SEED 3_tmj8-25-17.doc	No	Fillable Fileable
Instruction	Attachment 16.b. Saliva Collection Instructions Form SEED 3.docx	No	Paper Only
Other-WORD	Attachment 16.c. Saliva Consent Form SEED 3.docx	No	Fillable Fileable Signable
Other-WORD	Attachment 16.d. Saliva Transmittal Form SEED 3_tmj8-25-17.doc	No	Fillable Fileable
Other-WORD	Attachment 17.b. Adult Blood Draw Form SEED 3_tmj8-25-17.doc	No	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 234

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	234	234
Annual IC Time Burden (Hours)	351	351
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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