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Great Lakes Healthcare Providers Comprehensive Follow-up
Fetal Alcohol Spectrum Disorders Regional Training Centers
OMB: 0920-0954
IC ID: 204251
OMB.report
HHS/CDC
OMB 0920-0954
ICR 201209-0920-008
IC 204251
( )
Documents and Forms
Document Name
Document Type
Great Lakes Healthcare Providers Comprehensive Follow-up
Form
Great Lakes Comprehensive Follow-up
E12a_screenshots Great Lakes FASD RegionalTraining Center QUALTRICS FASD Com.pdf
Form
E11_Great Lakes FASD RegionalTraining Center FASD Comprehensive_1.docx
Great Lakes Comprehensive Follow-up - Word
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Great Lakes Healthcare Providers Comprehensive Follow-up
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
none
Great Lakes Comprehensive Follow-up
E12a_screenshots Great Lakes FASD RegionalTraining Center QUALTRICS FASD Com.pdf
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Consumer Health and Safety
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
204
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
100 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
204
0
204
0
0
0
Annual IC Time Burden (Hours)
51
0
51
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Great Lakes Comprehensive Follow-up - Word
E11_Great Lakes FASD RegionalTraining Center FASD Comprehensive_1.docx
09/19/2012
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.