View Information Collection (IC)

View Information Collection (IC)

IC Title:	Unlicensed Facility UC Questionnaires (M-12A-UF to M-12B-UF & M-12E-UF) - Respondents	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

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 M-12A-UF	UC Questionnaire - Ages 6-12 Years Old English	11a - UC Questionnaire - Ages 6-12 Years Old English (Form M-12A-UF).docx		Yes	Yes	Fillable Fileable
Form and Instruction	Form M-12As-UF	UC Questionnaire - Ages 6-12 Years Old Spanish	11b - UC Questionnaire - Ages 6-12 Years Old Spanish (Form M-12As-UF).docx		Yes	Yes	Fillable Fileable
Form and Instruction	Form M-12B-UF	UC Questionnaire - Ages 13 and Older English	12a - UC Questionnaire - Ages 13 and Older English (Form M-12B-UF).docx		Yes	Yes	Fillable Fileable
Form and Instruction	Form M-12Bs-UF	UC Questionnaire - Ages 13 and Older Spanish	12b -UC Questionnaire - Ages 13 and Older Spanish (Form M-12Bs-UF).docx		Yes	Yes	Fillable Fileable
Form and Instruction	Form M-12E-UF	UC Questionnaire - Ages 5 and Under - English	13a - UC Questionnaire - Ages 5 and Under - English (Form M-12E-UF).docx		Yes	Yes	Fillable Fileable
Form and Instruction	Form M-12Es-UF	UC Questionnaire - Ages 5 and Under Spanish	13b - UC Questionnaire - Ages 5 and Under Spanish (Form M-12Es-UF).docx		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,120	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	1,120	0	1,120	0	0	0
Annual IC Time Burden (Hours)	560	0	560	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	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.