Information Collection

Behavioral Assessment

IC 200523 under ICR 201112-0920-011 · OMB 0920-0928.

Documents and Forms

Document Name Document Type
Behavioral Assessment Form
Behavioral Assessment - Spanish version Att 3b Behavioral Assessment Survey (Spanish).docx Form
Behavioral Assessment Survey (English) Att 2b Behavioral Assessment Survey.docx Form
Att 2c Screen Shots of Survey.pdf Att 2c - Screenshots IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Behavioral Assessment	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	Behavioral Assessment - Spanish version	Att 3b Behavioral Assessment Survey (Spanish).docx		Yes	Yes	Fillable Fileable
Form	none	Behavioral Assessment Survey (English)	Att 2b Behavioral Assessment Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 170,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	170,000	170,000
Annual IC Time Burden (Hours)	39,667	39,667
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att 2c - Screenshots	Att 2c Screen Shots of Survey.pdf	12/15/2011

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