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MUH Resident Baseline Survey - Children's Module LA
Adoption, Health Impact and Cost of Smoke-Free Multi-Unit Housing Policies
OMB: 0920-1004
IC ID: 204444
OMB.report
HHS/CDC
OMB 0920-1004
ICR 201309-0920-011
IC 204444
( )
Documents and Forms
Document Name
Document Type
MUH Resident Baseline Survey - Children's Module LA
Form
MUH Resident Baseline - Children's Module section G
clean 12.17.13Att 8A(e)_MUH Resident Baseline Survey.doc
Form
MUH Resident Baseline - Children's Module section G Span
clean 12.17.13 Att 8A(s)_MUH Resident Baseline Survey_12.15.13.doc
Form
clean 12.17.13 Att 8A-1(e) MUH Resident Adult Participant Consent_9.3.......docx
Consent Adult
IC Document
clean 12 17. 13 Att 8A-1(s) MUH Resident Adult Participant Consent_9 3 1....docx
Consent Adult Spanish
IC Document
Att 8A-2(e) MUHAdult Resident HIPPA form_9.3.13.docx
IRB Authorization
IC Document
Att 8A-2(s) MUHAdult Resident HIPPA form 9.3.13.docx
IRB Authoization Spanish
IC Document
clean 12.17.13 Att 8A-3(e) LA Resident Consent for Child Questions_9.3......docx
Consent Child
IC Document
clean 12 17 13 Att 8A-3(s) LA Resident Consent for Child Questions_9 3 1....docx
Consent Child Spanish
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
MUH Resident Baseline Survey - Children's Module LA
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
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
MUH Resident Baseline - Children's Module section G
clean 12.17.13Att 8A(e)_MUH Resident Baseline Survey.doc
Yes
No
Fillable Printable
Form
none
MUH Resident Baseline - Children's Module section G Spanish
clean 12.17.13 Att 8A(s)_MUH Resident Baseline Survey_12.15.13.doc
Yes
No
Fillable Printable
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 %
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
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
Consent Adult
clean 12.17.13 Att 8A-1(e) MUH Resident Adult Participant Consent_9.3.......docx
12/19/2013
Consent Adult Spanish
clean 12 17. 13 Att 8A-1(s) MUH Resident Adult Participant Consent_9 3 1....docx
12/19/2013
IRB Authorization
Att 8A-2(e) MUHAdult Resident HIPPA form_9.3.13.docx
09/23/2013
IRB Authoization Spanish
Att 8A-2(s) MUHAdult Resident HIPPA form 9.3.13.docx
09/23/2013
Consent Child
clean 12.17.13 Att 8A-3(e) LA Resident Consent for Child Questions_9.3......docx
12/19/2013
Consent Child Spanish
clean 12 17 13 Att 8A-3(s) LA Resident Consent for Child Questions_9 3 1....docx
12/19/2013
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.