Information Collection

Unlicensed Facility UC Questionnaires (M-12A-UF to M-12B-UF & M-12E-UF) - Recordkeeping

IC 256790 under ICR 202211-0970-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form Form M-12A-UF Unlicensed Facility UC Questionnaires (M-12A-UF to M-12B-UF & M-12E-UF) - Recordkeeping Form and Instruction
Form M-12A-UF UC Questionnaire - Ages 6-12 Years Old English 11a - UC Questionnaire - Ages 6-12 Years Old English (Form M-12A-UF).docx Form and Instruction
Form M-12As-UF UC Questionnaire - Ages 6-12 Years Old Spanish 11b - UC Questionnaire - Ages 6-12 Years Old Spanish (Form M-12As-UF).docx Form and Instruction
Form M-12B-UF UC Questionnaire - Ages 13 and Older English 12a - UC Questionnaire - Ages 13 and Older English (Form M-12B-UF).docx Form and Instruction
Form M-12Bs-UF UC Questionnaire - Ages 13 and Older Spanish 12b -UC Questionnaire - Ages 13 and Older Spanish (Form M-12Bs-UF).docx Form and Instruction
Form M-12E-UF UC Questionnaire - Ages 5 and Under - English 13a - UC Questionnaire - Ages 5 and Under - English (Form M-12E-UF).docx Form and Instruction
Form M-12Es-UF UC Questionnaire - Ages 5 and Under Spanish 13b - UC Questionnaire - Ages 5 and Under Spanish (Form M-12Es-UF).docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Unlicensed Facility UC Questionnaires (M-12A-UF to M-12B-UF & M-12E-UF) - Recordkeeping	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form M-12A-UF	UC Questionnaire - Ages 6-12 Years Old English	11a - UC Questionnaire - Ages 6-12 Years Old English (Form M-12A-UF).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-12As-UF	UC Questionnaire - Ages 6-12 Years Old Spanish	11b - UC Questionnaire - Ages 6-12 Years Old Spanish (Form M-12As-UF).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-12B-UF	UC Questionnaire - Ages 13 and Older English	12a - UC Questionnaire - Ages 13 and Older English (Form M-12B-UF).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-12Bs-UF	UC Questionnaire - Ages 13 and Older Spanish	12b -UC Questionnaire - Ages 13 and Older Spanish (Form M-12Bs-UF).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-12E-UF	UC Questionnaire - Ages 5 and Under - English	13a - UC Questionnaire - Ages 5 and Under - English (Form M-12E-UF).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-12Es-UF	UC Questionnaire - Ages 5 and Under Spanish	13b - UC Questionnaire - Ages 5 and Under Spanish (Form M-12Es-UF).docx	Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 18	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,116	1,116
Annual IC Time Burden (Hours)	558	558
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.