Information Collection

Los Angeles Unified School District School Health Climate and Service Assessment Survey

IC 213073 under ICR 201409-0920-007 · OMB 0920-1048.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1048 can be found here:

Documents and Forms

Document Name Document Type
Los Angeles Unified School District School Health Climate and Service Assessment Survey Form
Los Angeles Unified School District School Helath Climat Att 7-Screens_LA.docx Form
Att 16-Consent_LA.docx Los Angeles Unified Schools Informed Consent IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Los Angeles Unified School District School Health Climate and Service Assessment Survey	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
Form	None	Los Angeles Unified School District School Helath Climate and Service Assessment Survey	Att 7-Screens_LA.docx	None	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 163	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	163	163
Annual IC Time Burden (Hours)	68	68
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Los Angeles Unified Schools Informed Consent	Att 16-Consent_LA.docx	09/10/2014

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