Information Collection

Great Lakes Healthcare Providers ID and Treatment Follow-up

IC 204248 under ICR 201209-0920-008 · OMB 0920-0954.

Documents and Forms

Document Name Document Type
Great Lakes Healthcare Providers ID and Treatment Follow-up Form
Great Lakes ID and Treatment Follow-up E9a_screenshots Great Lakes FASD RTCQUALTRICS Identification and Treatment.pdf Form
E9_Great Lakes FASD RegionalTraining Center Identification and.docx Great Lakes ID and Treatment Follow-up- Word IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Great Lakes Healthcare Providers ID and Treatment 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 ID and Treatment Follow-up	E9a_screenshots Great Lakes FASD RTCQUALTRICS Identification and Treatment.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: 258	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	258	258
Annual IC Time Burden (Hours)	34	34
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Great Lakes ID and Treatment Follow-up- Word	E9_Great Lakes FASD RegionalTraining Center Identification and.docx	09/19/2012

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