Information Collection

Child/Youth Assessment and Referral Tool

IC 278721 under ICR 202601-0930-001 · OMB 0930-0270.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Child/Youth Assess Child/Youth Assessment and Referral Tool	Form and Instruction
Form Child/Youth Assess Child/Youth Assessment and Referral Tool Child/Youth Assessment and Referral Tool	Form and Instruction
Child/Youth Assess Child/Youth Assessment and Referral Tool Attach E dtac-ccp-toolkit-child-youth-assessment-referral-tool.pdf	Form and Instruction
Child/Youth Assess Child/Youth Assessment and Referral Tool Attach E dtac-ccp-toolkit-child-youth-assessment-referral-tool.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	Child/Youth Assessment and Referral Tool				Yes	Yes	Fillable Fileable

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: 800

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	800	800
Annual IC Time Burden (Hours)	64	64
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.

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