Information Collection

Student Identification and Referral Form

IC 266683 under ICR 202404-0930-003 · OMB 0930-0398.

Documents and Forms

Document Name Document Type
Form Student Identifica Student Identification and Referral Form Form and Instruction
Student Identifica Student Identification and Referral Form Att.M_SIRF for OMB_CLEAN_04092024.docx Form and Instruction
Student Identifica Student Identification and Referral Form Att.M_SIRF for OMB_CLEAN_05292024.docx Form and Instruction
4. Project AWARE-TISS Cross-Site Evaluation Part A.docx Supporting Statement A IC Document
4. Project AWARE-TISS Cross-Site Evaluation Part A.docx Supporting Statement A IC Document
5. Project AWARE-TISS Cross-Site Evaluation Part B.docx Supporting Statement B IC Document
5. Project AWARE-TISS Cross-Site Evaluation Part B.docx Supporting Statement B IC Document
Att.N_ ATODS DUA for OMB_Final Clean_09062023.docx Data Access and Use Agreement IC Document
Att.N_ ATODS DUA for OMB_Final Clean_09062023.docx Data Access and Use Agreement IC Document
ATT.O_Project AWARE-TISS Cross-Site Evaluation Questions for OMB_Final Clean_09062023.docx Cross-Site Evaluation Questions IC Document
ATT.O_Project AWARE-TISS Cross-Site Evaluation Questions for OMB_Final Clean_09062023.docx Cross-Site Evaluation Questions IC Document
ATT.P_Detailed Description of Project AWARE-TISS Cross-Site Evaluation Components for OMB_Final Clean_09062023.docx Detailed Description of AWARE TISS Evaluation Components IC Document
ATT.P_Detailed Description of Project AWARE-TISS Cross-Site Evaluation Components for OMB_Final Clean_09062023.docx Detailed Description of AWARE TISS Evaluation Components IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Student Identification and Referral Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Student Identification and Referral Form	Student Identification and Referral Form	Att.M_SIRF for OMB_CLEAN_05292024.docx		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: Privacy Act of 1974 (Title 5 United States Code [U.S.C.] 552a)	FR Citation: 75 FR 28264

Number of Respondents: 47	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,700	4,700
Annual IC Time Burden (Hours)	2,350	2,350
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement A	4. Project AWARE-TISS Cross-Site Evaluation Part A.docx	04/08/2024
Supporting Statement B	5. Project AWARE-TISS Cross-Site Evaluation Part B.docx	04/08/2024
Data Access and Use Agreement	Att.N_ ATODS DUA for OMB_Final Clean_09062023.docx	04/08/2024
Cross-Site Evaluation Questions	ATT.O_Project AWARE-TISS Cross-Site Evaluation Questions for OMB_Final Clean_09062023.docx	04/08/2024
Detailed Description of AWARE TISS Evaluation Components	ATT.P_Detailed Description of Project AWARE-TISS Cross-Site Evaluation Components for OMB_Final Clean_09062023.docx	04/08/2024

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