CAPP Caregiver Questionnaire

Permanency Innovations Initiative (PII) Evaluation - Phase 4

Documents and Forms

Document Name Document Type
Attachment A4a Caregiver Informed Consent and Questionnaire Paper.PDF Other-Questionnaire
Attachment A6a-9 Caregiver IC-Questionnaire Telephone-10_15-FINAL.DOCX Other-Questionnaire
Attachment A4b Caregiver Informed Consent and Questionnaire Paper Scantron Spanish 10-15.pdf Attachment A4b Caregiver Informed Consent and Questionnaire Paper Scantron Spanish IC Document
Attachment A6b_ Caregiver IC-Questionnaire Telephone Spanish-10_15-FINA....docx Attachment A6b Caregiver IC-Questionnaire Telephone Spanish IC Document

Information Collection (IC) Details

IC Title:	CAPP Caregiver Questionnaire	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
Other-Questionnaire			Attachment A4a Caregiver Informed Consent and Questionnaire Paper.PDF		No		Paper Only
Other-Questionnaire			Attachment A6a-9 Caregiver IC-Questionnaire Telephone-10_15-FINAL.DOCX		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 587	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	587	587
Annual IC Time Burden (Hours)	352	352
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment A4b Caregiver Informed Consent and Questionnaire Paper Scantron Spanish	Attachment A4b Caregiver Informed Consent and Questionnaire Paper Scantron Spanish 10-15.pdf	11/17/2015
Attachment A6b Caregiver IC-Questionnaire Telephone Spanish	Attachment A6b_ Caregiver IC-Questionnaire Telephone Spanish-10_15-FINA....docx	11/17/2015

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