Information Collection

Follow-up Assessment

IC 232936 under ICR 201807-0920-013 · OMB 0920-1246.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1246 can be found here:

Documents and Forms

Document Name Document Type
Follow-up Assessment Form
TLC Follow Up Assessment Att 4d_TLC Follow Up Assessment_23Aug2018.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Follow-up 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	n/a	TLC Follow Up Assessment	Att 4d_TLC Follow Up Assessment_23Aug2018.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems HHS/CDC	FR Citation: 57 FR 62812

Number of Respondents: 75	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	150	150
Annual IC Time Burden (Hours)	150	150
Annual IC Cost Burden (Dollars)	3,651	3,651

Documents for IC

Title	Document	Date Uploaded
No associated records found

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