Institutional Awareness and Commitment Survey (State Health Departments)

Institutional Awareness and Commitment to Ensuring Safe, Stable, and Nurturing Relationships and Environments for Children

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1010 can be found here:

Documents and Forms

Document Name Document Type
Attachment D - Survey.docx Other-WORD
Attachment C - Survey Screenshots.pdf Attachment C - Survey Screenshots IC Document
Attachment E- Email Invitation.docx Attachment E- Email Invitation IC Document
Attachment F - Email Invitation Follow-up.docx Attachment F - Email Invitation Follow-up IC Document

Information Collection (IC) Details

IC Title:	Institutional Awareness and Commitment Survey (State Health Departments)	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
Other-WORD			Attachment D - Survey.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 8	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	8	8
Annual IC Time Burden (Hours)	4	4
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment C - Survey Screenshots	Attachment C - Survey Screenshots.pdf	02/06/2014
Attachment E- Email Invitation	Attachment E- Email Invitation.docx	02/06/2014
Attachment F - Email Invitation Follow-up	Attachment F - Email Invitation Follow-up.docx	02/06/2014

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