Information Collection

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

IC 201913 under ICR 201204-0920-001 · OMB 0920-0930.

Documents and Forms

Documents and forms in this information collection
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

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 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 %

table that charts list of burden
	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

table that charts IC Documents
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.