Information Collection

3-Month Follow-up Questionnaire

IC 199773 under ICR 201110-0920-008 · OMB 0920-0913.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0913 can be found here:

Documents and Forms

Document Name Document Type
Attachment 3g 3- and 6-month Follow up Questionnaire 6.16.11.doc Other-WORD
Att 3j Follow-up interview log 082511.docx Att 3j Follow-up interview log 082511 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	3-Month Follow-up Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 241

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-WORD			Attachment 3g 3- and 6-month Follow up Questionnaire 6.16.11.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 420	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	420	420
Annual IC Time Burden (Hours)	420	420
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att 3j Follow-up interview log 082511	Att 3j Follow-up interview log 082511.docx	10/14/2011

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