Information Collection

Preventing Adverse Childhood Experiences Pediatric Medical Provider Module Online Course

IC 237904 under ICR 201612-0920-007 · OMB 0920-1009.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

0920-1009-19BSM

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.