Information Collection

Safe Dates Implementation Survey

IC 199975 under ICR 201110-0920-012 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 12 Safe Dates Implementation Survey	Form
12 Safe Dates Implementation Survey Attachment S rev - Student+Curricula+Implementation+Survey.docx	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	12	Safe Dates Implementation Survey	Attachment S rev - Student+Curricula+Implementation+Survey.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 144

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 20 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	144	144
Annual IC Time Burden (Hours)	144	144
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.