Preventing Adverse Childhood Experiences Pediatric Medical Provider Module Online Course

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

Documents and Forms

Document Name Document Type
Form 0920-1009 Preventing Adverse Childhood Experiences Pediatric Medical Provider Module Online Course Form and Instruction
0920-1009 Course Evaluation Questions Att 1_Course Evaluation Questions.doc Form and Instruction
109_GenIC_Request_ACEs Pediatric Medical Provider Prevention Online Course_092419 (004).docx GenIC Request Template form IC Document
Att2_PIA Applicability.pdf Privacy Assessment IC Document

Information Collection (IC) Details

IC Title:	Preventing Adverse Childhood Experiences Pediatric Medical Provider Module Online Course	Agency IC Tracking Number:	0920-1009-19BSM

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	0920-1009	Course Evaluation Questions	Att 1_Course Evaluation Questions.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,500	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	4,500	4,500
Annual IC Time Burden (Hours)	225	225
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
GenIC Request Template form	109_GenIC_Request_ACEs Pediatric Medical Provider Prevention Online Course_092419 (004).docx	09/27/2019
Privacy Assessment	Att2_PIA Applicability.pdf	09/27/2019

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