Information Collection

Caregiver Survey

IC 203632 under ICR 201305-0920-002 · OMB 0920-0977.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Caregiver Survey	Form
Caregiver Survey Att 9A_CaregiverSurvey.docx	Form
Caregiver Survey - Spanish Att 9A-S_CaregiverSurvey_SP.docx	Form
Att 9C_Youth_CaregiverSurvey_ItemSources_2013_0618.pdf Att 9C_Youth_CaregiverSurvey_ItemSources_2013_0618	IC Document

IC Title:

Caregiver Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	none	Caregiver Survey	Att 9A_CaregiverSurvey.docx		Yes	Yes	Fillable Fileable
Form	none	Caregiver Survey - Spanish	Att 9A-S_CaregiverSurvey_SP.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title: Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 960

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	960	960
Annual IC Time Burden (Hours)	320	320
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 9C_Youth_CaregiverSurvey_ItemSources_2013_0618	Att 9C_Youth_CaregiverSurvey_ItemSources_2013_0618.pdf	08/06/2013

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