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Essentials Instrument and Protocol Evaluation and Surveillance Survey
[NCIPC] Reporting of the Essentials for Childhood (EfC): Preventing Adverse Childhood Experiences through Data to Action Program
OMB: 0920-1425
IC ID: 262777
OMB.report
HHS/CDC
OMB 0920-1425
ICR 202310-0920-004
IC 262777
( )
Documents and Forms
Document Name
Document Type
Form 0920
Essentials Instrument and Protocol Evaluation and Surveillance Survey
Form and Instruction
0920 Essentials Instrument and Protocol Evaluation and Survei
Att. 6 Evaluation and Surveillance Survey.docx
Form and Instruction
0920 Essentials Instrument and Protocol Evaluation and Survei
Att. 6 Evaluation and Surveillance Survey.docx
Form and Instruction
Att. 6a Evaluation and Surveillance Survey Screenshot.pdf
Essentials for Childhood: Preventing ACEs Evaluation and Surveillance Survey
IC Document
Att. 6a Evaluation and Surveillance Survey Screenshot.pdf
Essentials for Childhood: Preventing ACEs Evaluation and Surveillance Survey
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Essentials Instrument and Protocol Evaluation and Surveillance Survey
Agency IC Tracking Number:
0920-23DT
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
0920
Essentials Instrument and Protocol Evaluation and Surveillance Survey
Att. 6 Evaluation and Surveillance Survey.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Public Health Monitoring
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
12
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 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
12
0
12
0
0
0
Annual IC Time Burden (Hours)
12
0
12
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Essentials for Childhood: Preventing ACEs Evaluation and Surveillance Survey
Att. 6a Evaluation and Surveillance Survey Screenshot.pdf
10/25/2023
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.