Information Collection

Eligible and consenting participants - Behavioral Assessment Interview

IC 234907 under ICR 202301-0920-002 · OMB 0920-1262.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1262 Eligible and consenting participants - Behavioral Assessment Interview	Form and Instruction
0920-1262 Behavioral Assessment (English) Att 4b_Behavioral Assessment (English)_rev 12092022.docx	Form and Instruction
0920-1262 Behavioral Assessment (English) Att 4b_Behavioral Assessment (English)_rev 12092022.docx	Form and Instruction
0920-1262 Behavioral Assessment (Spanish) Att 5b_Behavioral Assessment (Spanish)_rev 12092022.docx	Form and Instruction
0920-1262 Behavioral Assessment (Spanish) Att 5b_Behavioral Assessment (Spanish)_rev 12092022.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-1262-23BS

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	0920-1262	Behavioral Assessment (English)	Att 4b_Behavioral Assessment (English)_rev 12092022.docx		Yes	Yes	Fillable Fileable
Form and Instruction	0920-1262	Behavioral Assessment (Spanish)	Att 5b_Behavioral Assessment (Spanish)_rev 12092022.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 76 FR 4458

Number of Respondents: 1,400

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	1,400	1,400
Annual IC Time Burden (Hours)	933	933
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.