Screening and Diagnosis Tool

Fetal Alcohol Spectrum Disorders (FASD) Center for Excellence Diagnosis and Intervention Project

Documents and Forms

Document Name Document Type
Form Form A - DxInt. Sc Screening and Diagnosis Tool Form and Instruction
Form A - DxInt. Sc Form A - DxInt. Screening A- DxInt. Screening.doc Form and Instruction
Consent forms.pdf Consent Forms IC Document

Information Collection (IC) Details

IC Title:	Screening and Diagnosis Tool	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 and Instruction	Form A - DxInt. Screening	Form A - DxInt. Screening	A- DxInt. Screening.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,500	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,500	1,500
Annual IC Time Burden (Hours)	255	255
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Consent Forms	Consent forms.pdf	05/27/2010

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