Information Collection

UC Questionnaires (Forms M-12A-B, E) - Respondents

IC 245614 under ICR 202112-0970-003 · OMB 0970-0564.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0564 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form M-12A UC Questionnaires (Forms M-12A-B, E) - Respondents	Form and Instruction
Form M-12A UC Questionnaire - Ages 6-12 Years Old - English M-12A UC Questionnaire - Ages 6-12 Years Old - Clean.docx	Form and Instruction
Form M-12A UC Questionnaire - Ages 6-12 Years Old - English M-12A UC Questionnaire - Ages 6-12 Years Old - Clean.docx	Form and Instruction
Form M-12B UC Questionnaire - Ages 13 and Older - English M-12B UC Questionnaire - Ages 13 and Older - Clean.docx	Form and Instruction
Form M-12B UC Questionnaire - Ages 13 and Older - English M-12B UC Questionnaire - Ages 13 and Older - Clean.docx	Form and Instruction
Form M-12E UC Questionnaire - Ages 5 and Under - English UC Questionnaire - Ages 5 and Under - English (Form M-12E).docx	Form and Instruction
Form M-12E UC Questionnaire - Ages 5 and Under - English UC Questionnaire - Ages 5 and Under - English (Form M-12E).docx	Form and Instruction
Form M-12As UC Questionnaire - Ages 6-12 Years Old - Spanish UC Questionnaire - Ages 6-12 Years Old - Spanish (Form M-12As).docx	Form and Instruction
Form M-12As UC Questionnaire - Ages 6-12 Years Old - Spanish UC Questionnaire - Ages 6-12 Years Old - Spanish (Form M-12As).docx	Form and Instruction
Form M-12Bs UC Questionnaire - Ages 13 and Older - Spanish UC Questionnaire - Ages 13 and Older - Spanish (Form M-12Bs).docx	Form and Instruction
Form M-12Bs UC Questionnaire - Ages 13 and Older - Spanish UC Questionnaire - Ages 13 and Older - Spanish (Form M-12Bs).docx	Form and Instruction
Form M-12Es UC Questionnaire - Ages 5 and Under - Spanish UC Questionnaire - Ages 5 and Under - Spanish (Form M-12Es).docx	Form and Instruction
Form M-12Es UC Questionnaire - Ages 5 and Under - Spanish UC Questionnaire - Ages 5 and Under - Spanish (Form M-12Es).docx	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

UC Questionnaires (Forms M-12A-B, E) - Respondents

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form M-12A	UC Questionnaire - Ages 6-12 Years Old - English	M-12A UC Questionnaire - Ages 6-12 Years Old - Clean.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-12B	UC Questionnaire - Ages 13 and Older - English	M-12B UC Questionnaire - Ages 13 and Older - Clean.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-12E	UC Questionnaire - Ages 5 and Under - English	UC Questionnaire - Ages 5 and Under - English (Form M-12E).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-12As	UC Questionnaire - Ages 6-12 Years Old - Spanish	UC Questionnaire - Ages 6-12 Years Old - Spanish (Form M-12As).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-12Bs	UC Questionnaire - Ages 13 and Older - Spanish	UC Questionnaire - Ages 13 and Older - Spanish (Form M-12Bs).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-12Es	UC Questionnaire - Ages 5 and Under - Spanish	UC Questionnaire - Ages 5 and Under - Spanish (Form M-12Es).docx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 460

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	460	460
Annual IC Time Burden (Hours)	230	230
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.