Information Collection

Phase 2 Behavioral Survey

IC 218947 under ICR 202112-0920-002 · OMB 0920-1100.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1100 Phase 2 Behavioral Survey	Form and Instruction
0920-1100 Att 8a_Phase 2 Behavioral Survey (English) Att 8a_Phase 2 Behavioral Survey (English).docx	Form and Instruction
0920-1100 Att 8a_Phase 2 Behavioral Survey (English) Att 8a_Phase 2 Behavioral Survey (English).docx	Form and Instruction
0920-1100 Att 8b_Phase 2 Behavioral Survey (Spanish) Att 8b_Phase 2 Behavioral Survey (Spanish).docx	Form and Instruction
0920-1100 Att 8b_Phase 2 Behavioral Survey (Spanish) Att 8b_Phase 2 Behavioral Survey (Spanish).docx	Form and Instruction
Att 12b_Screenshots_REDCaP_Phase 2 Behavioral Survey (Spanish).pdf Att 12b_Screenshots_REDCaP_Phase 2 Behavioral Survey (Spanish)	IC Document
Att 12b_Screenshots_REDCaP_Phase 2 Behavioral Survey (Spanish).pdf Att 12b_Screenshots_REDCaP_Phase 2 Behavioral Survey (Spanish)	IC Document
Att 12a_Screenshots_REDCaP_Phase 2 Behavioral Survey.pdf Att 12a_Screenshots_REDCaP_Phase 2 Behavioral Survey	IC Document
Att 12a_Screenshots_REDCaP_Phase 2 Behavioral Survey.pdf Att 12a_Screenshots_REDCaP_Phase 2 Behavioral Survey	IC Document

IC Title:

Agency IC Tracking Number:

0920-1100

Is this a Common Form? No

IC Status: Modified

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 and Instruction	0920-1100	Att 8a_Phase 2 Behavioral Survey (English)	Att 8a_Phase 2 Behavioral Survey (English).docx		Yes	Yes	Fillable Fileable
Form and Instruction	0920-1100	Att 8b_Phase 2 Behavioral Survey (Spanish)	Att 8b_Phase 2 Behavioral Survey (Spanish).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

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
	Approved	Previously Approved
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	25	25
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 12b_Screenshots_REDCaP_Phase 2 Behavioral Survey (Spanish)	Att 12b_Screenshots_REDCaP_Phase 2 Behavioral Survey (Spanish).pdf	12/07/2021
Att 12a_Screenshots_REDCaP_Phase 2 Behavioral Survey	Att 12a_Screenshots_REDCaP_Phase 2 Behavioral Survey.pdf	12/07/2021

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