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MUH Resident Baseline Survey - Children's Module - LA County
Adoption, Health Impact and Cost of Smoke-Free Multi-Unit Housing Policies
OMB: 0920-1004
IC ID: 204442
OMB.report
HHS/CDC
OMB 0920-1004
ICR 201210-0920-003
IC 204442
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1004 can be found here:
2013-09-30 - New collection (Request for a new OMB Control Number)
Documents and Forms
Document Name
Document Type
MUH Resident Baseline Survey - Children's Module - LA County
Form
Resident Survey - Children's Module - LA County -English
Att 8A(e)_MUH Resident Baseline Survey_8 30 2012.doc
Form
Resident Survey - Children's Module -LA County - Spanish
Att 8A(s)_MUH Resident Baseline Survey_8 30 2012.doc
Form
Att 8A-1(e)_MUH Resident Adult Consent.docx
Adult Consent - English
IC Document
Att 8A-1(s)_MUH Resident Adult Consent_8 30 2012.docx
Adult Consent- Spanish
IC Document
Att 8A-2(e)_LA HIPPA Form.docx
LA HIPPA - English
IC Document
Att 8A-2(s)_LA HIPPA Form_8 30 2012.docx
LA HIPPA - Spanish
IC Document
Att 8A-3(e)_LA Resident Consent for Child Questions.docx
Child Consent - English
IC Document
Att 8A-3(s)_LA Resident Consent for Child Questions_8 30 2012.docx
Child Consent - Spanish
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
MUH Resident Baseline Survey - Children's Module - LA County
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
Resident Survey - Children's Module - LA County -English
Att 8A(e)_MUH Resident Baseline Survey_8 30 2012.doc
No
No
Paper Only
Form
none
Resident Survey - Children's Module -LA County - Spanish
Att 8A(s)_MUH Resident Baseline Survey_8 30 2012.doc
No
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Immunization Management
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
250
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Requested
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
250
0
250
0
0
0
Annual IC Time Burden (Hours)
63
0
63
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Adult Consent - English
Att 8A-1(e)_MUH Resident Adult Consent.docx
09/27/2012
Adult Consent- Spanish
Att 8A-1(s)_MUH Resident Adult Consent_8 30 2012.docx
09/27/2012
LA HIPPA - English
Att 8A-2(e)_LA HIPPA Form.docx
09/27/2012
LA HIPPA - Spanish
Att 8A-2(s)_LA HIPPA Form_8 30 2012.docx
09/27/2012
Child Consent - English
Att 8A-3(e)_LA Resident Consent for Child Questions.docx
09/27/2012
Child Consent - Spanish
Att 8A-3(s)_LA Resident Consent for Child Questions_8 30 2012.docx
09/27/2012
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.