[NCIPC] Adverse Childhood Experiences Prevention Message Development

[OS] CDC/ATSDR Formative Research and Tool Development

OMB: 0920-1154

IC ID: 270987

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1154 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-1154 [NCIPC] Adverse Childhood Experiences Prevention Message Development Form and Instruction
Att 2. ACEs Survey Screenshots_8.7.24ka.docx Other-Screenshots
Att 2. ACEs Survey Screenshots_8.7.24ka.docx Other-Screenshots
Att 5. ACEs Focus Group Guide_v2.docx Instruction
Att 5. ACEs Focus Group Guide_v2.docx Instruction
0920-1154 ACEs Survey and Consent - Revised 25MAR2025 Att 1. ACEs Survey and Consent__OMB Edited 12.2.24.docx Form and Instruction
0920-1154 ACEs Survey and Consent - Revised 25MAR2025 Att 1. ACEs Survey and Consent__OMB Edited 12.2.24.docx Form and Instruction
0920-1154 ACEs Focus Group Participant Screener - Revised 25MAR202 Att 3. ACEs Focus Group Participant Screener_OMB Edited12.2.24.docx Form and Instruction
0920-1154 ACEs Focus Group Participant Screener - Revised 25MAR202 Att 3. ACEs Focus Group Participant Screener_OMB Edited12.2.24.docx Form and Instruction
0920-1154 (24IP) ACEs Focus Group Consent Form Att 4. ACEs Focus Group Consent_v3.docx Form and Instruction
0920-1154 (24IP) ACEs Focus Group Consent Form Att 4. ACEs Focus Group Consent_v3.docx Form and Instruction
0920-1154 (24IP) ACEs Partner Interview Consent Form Att 6. ACEs Partner Interview Consent Form_v3.docx Form and Instruction
0920-1154 (24IP) ACEs Partner Interview Consent Form Att 6. ACEs Partner Interview Consent Form_v3.docx Form and Instruction
0920-1154 (24IP) ACEs Partner Interview Guide Att 7. ACEs Partner Interview Guide_v2.docx Form and Instruction
0920-1154 (24IP) ACEs Partner Interview Guide Att 7. ACEs Partner Interview Guide_v2.docx Form and Instruction
ACE Prevention Message SSA_OMB Corrected 12.02.24.docx SSA (24IP) IC Document
ACE Prevention Message SSA_OMB Corrected 12.02.24.docx SSA (24IP) IC Document
ACE Prevention Message SSB__8.7.24ka.docx SSB (24IP) IC Document
ACE Prevention Message SSB__8.7.24ka.docx SSB (24IP) IC Document
Att 8. ACEs Messages for Testing_v1.docx ACEs Messages for Testing (24IP) IC Document
Att 8. ACEs Messages for Testing_v1.docx ACEs Messages for Testing (24IP) IC Document
Att 10. ACEs Non-Research determination.docx Project Determination (24IP) IC Document
Att 10. ACEs Non-Research determination.docx Project Determination (24IP) IC Document
ACE Prevention Message SSB_tracked changes.docx Revised Supporting Statement B 25MAR2025 IC Document
ACE Prevention Message SSB_tracked changes.docx Revised Supporting Statement B 25MAR2025 IC Document
ACEs_0920-1154_Change Request Memo - EO14168.docx Change Request Memo 25MAR2025 IC Document
ACEs_0920-1154_Change Request Memo - EO14168.docx Change Request Memo 25MAR2025 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	[NCIPC] Adverse Childhood Experiences Prevention Message Development	Agency IC Tracking Number:	0920-1154-24IP

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-1154	N/A	Yes	Yes	Fillable Fileable
Other-Screenshots			No		Printable Only
Form and Instruction	0920-1154	N/A	Yes	Yes	Fillable Fileable
Form and Instruction	0920-1154 (24IP)		Yes	Yes	Fillable Fileable
Instruction			Yes	Yes	Fillable Fileable
Form and Instruction	0920-1154 (24IP)		Yes	Yes	Fillable Fileable
Form and Instruction	0920-1154 (24IP)		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 200	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	86	86
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SSA (24IP)		12/11/2024
SSB (24IP)		09/17/2024
ACEs Messages for Testing (24IP)		09/17/2024
Project Determination (24IP)		09/17/2024
Revised Supporting Statement B 25MAR2025		03/25/2025
Change Request Memo 25MAR2025		03/25/2025

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

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