Institutional Awareness and Commitment Survey (State Health Departments)

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

Documents and Forms

Document Name Document Type
Form 0920-1010 Institutional Awareness and Commitment Survey (State Health Departments) Form and Instruction
0920-1010 ICR Attachment D old survey w-tracked changes ICR Attachment D old survey w-tracked changes.docx Form and Instruction
0920-1010 Attachment D - Survey - New Attachment D - Survey - New.docx Form and Instruction
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
Attachment C - Survey - Screenshots of new instrument.pdf Attachment C - Survey - Screenshots of new instrument IC Document
ICRC Change Request Memo.docx ICRC Change Request Memo 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: Modified

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	0920-1010	ICR Attachment D old survey w-tracked changes	ICR Attachment D old survey w-tracked changes.docx		Yes	Yes	Fillable Fileable
Form and Instruction	0920-1010	Attachment D - Survey - New	Attachment D - Survey - New.docx		Yes	Yes	Fillable Fileable

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	Previously Approved
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 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
Attachment C - Survey - Screenshots of new instrument	Attachment C - Survey - Screenshots of new instrument.pdf	05/19/2014
ICRC Change Request Memo	ICRC Change Request Memo.docx	05/19/2014

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