Prevention Demonstration Project

Adolescent Family Life Care Demonstration Project End of Year Care Template (EOYC)

Documents and Forms

Document Name Document Type
eoy_instructions_care _and_prevention_doc_final.doc Instruction
EOY prevention template_final_8-13-09.doc Other-survey

Information Collection (IC) Details

IC Title:	Prevention Demonstration Project	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			eoy_instructions_care _and_prevention_doc_final.doc		Yes	Yes	Paper Only
Other-survey			EOY prevention template_final_8-13-09.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 35	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 25 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	35	35
Annual IC Time Burden (Hours)	2,275	2,275
Annual IC Cost Burden (Dollars)	0	0

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.