Information Collection

Great Lakes Health Care Providers SBI Pre-test

IC 204243 under ICR 201209-0920-008 · OMB 0920-0954.

Documents and Forms

Document Name Document Type
Great Lakes Health Care Providers SBI Pre-test Form
SBI Pre-test E4a_screenshots Great Lakes FASD RTC QUALTRICS Screenin.pdf Form
E4_Great Lakes FASD RegionalTraining Center Screening and Brief.docx SBI Pre-test - Word IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Great Lakes Health Care Providers SBI Pre-test	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	SBI Pre-test	E4a_screenshots Great Lakes FASD RTC QUALTRICS Screenin.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 120	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	120	120
Annual IC Time Burden (Hours)	16	16
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SBI Pre-test - Word	E4_Great Lakes FASD RegionalTraining Center Screening and Brief.docx	09/13/2012

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