CAPSA - AIF CAPSA Agency Information Form

OMB No. 1121-XXXX: Approval Expires XX/XX/XXXX

2014 Census of Adult Probation Supervising Agencies
FORM CAPSA-AIF

Agency Information Form

Please review the information below. Indicate whether the head of agency information is correct and make updates as needed. Also,
please designate a survey respondent and indicate whether the respondent would be able to complete the survey via the Internet.
Head of Agency

Information on file

Updated information

Agency Head Name:
Agency Name 1:
Agency Name 2:
Address 1:
Address 2:
City:

-

State, Zip:
Attn:
Email:

 - 
 - 

Phone:
Fax:

 - 
 - 

All information is correct.

Designated Survey Respondent
If requested, would the designated respondent be able to respond to the survey through the Internet?

Designated Respondent:

Agency Name 1:

Agency Name 2:

Address 1:

Address 2:

Yes

No

City:

State, Zip:

Attn:

Email:

-

 - 

 - 

Phone:

Fax:

 - 

 - 

Please turn to the next page for instructions on how to reply and for contact information.
Burden Statement: Under the Paperwork Reduction Act, we cannot ask you to respond to a collection of information unless it displays a currently valid OMB control number. Public
reporting burden for this collection is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering the
data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any aspect of this collection of information, including
suggestions for reducing this burden, to the Director, Bureau of Justice Statistics, 810 Seventh Street, NW, Washington, DC 20531; and to the Office of Management and Budget, OMB
No. 1121-XXXX, Washington, DC 20503.

Dev

Please fax or email this information to Westat by XX/XX, 2014
Fax: 301-279-4508
Email: [email protected]
Attn: CAPSA Survey
If you have any questions, please telephone 1-888-329-8124 or email [email protected].