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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

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-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 %

table that charts list of burden
	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

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.