School Level Survey

Mulit-Site Evaluation of the Safe Schools/Healthy Students (SS/HS) State Program

Documents and Forms

Document Name Document Type
Form School Level Surve School Level Survey Form and Instruction
School Level Surve School Level Survey Attachment H.1_School Level Survey_Implementation.docx Form and Instruction
Attachment H.2_School Level Survey Recruitment Script.pdf School Level Survey Recruitment Script IC Document

Information Collection (IC) Details

IC Title:	School Level 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 and Instruction	School Level Survey	School Level Survey	Attachment H.1_School Level Survey_Implementation.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,100	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	2,100	2,100
Annual IC Time Burden (Hours)	945	945
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
School Level Survey Recruitment Script	Attachment H.2_School Level Survey Recruitment Script.pdf	09/25/2014

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