Measuring Preferences for Quality of Life for Child Maltreatment Survey Instrument: Ages 18+

Measuring Preferences for Quality of Life for Child Maltreatment

Documents and Forms

Document Name Document Type
Form Attachment D Measuring Preferences for Quality of Life for Child Maltreatment Survey Instrument: Ages 18+ Form and Instruction
Attachment D Childhood Experiences Survey Attachment D - Survey Instrument 3-29-2012.docx Form and Instruction
Attachment E_Survey-Instrument.docx Attachment E_Survey-Instrument IC Document

Information Collection (IC) Details

IC Title:	Measuring Preferences for Quality of Life for Child Maltreatment Survey Instrument: Ages 18+	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
Form and Instruction	Attachment D	Childhood Experiences Survey	Attachment D - Survey Instrument 3-29-2012.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,100	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,100	1,100
Annual IC Time Burden (Hours)	458	458
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment E_Survey-Instrument	Attachment E_Survey-Instrument.docx	04/03/2012

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