Evaluation of the Safe Dates Project - Principle and Prevention Coordinator Mid-Implementation Survey

Evaluation of the Safe Dates Project

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0783 can be found here:

Documents and Forms

Document Name Document Type
APX B1 Mid-implementation Survey Principle.doc Instruction
Apx B1 Mid-Implementation Survey Program Coordinator.doc Prevention Coordinator Mid-Implementation Survey IC Document

Information Collection (IC) Details

IC Title:	Evaluation of the Safe Dates Project - Principle and Prevention Coordinator Mid-Implementation Survey	Agency IC Tracking Number:

Is this a Common Form? Yes		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
Instruction			APX B1 Mid-implementation Survey Principle.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 64	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	64	64
Annual IC Time Burden (Hours)	16	16
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Prevention Coordinator Mid-Implementation Survey	Apx B1 Mid-Implementation Survey Program Coordinator.doc	12/05/2007

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