Family/Caregiver Survey - CYSHCN

Effective Communication in Public Health Emergencies – Developing Community-Centered Tools for People with Special Health Care Needs

Documents and Forms

Document Name Document Type
Family/Caregiver Survey - CYSHCN Form and Instruction
CYSHCN Family/Caregiver Survey Attachment J. CYSHCN Family_Caregiver Survey.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Family/Caregiver Survey - CYSHCN	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	NA	CYSHCN Family/Caregiver Survey	Attachment J. CYSHCN Family_Caregiver Survey.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Disaster Management

Subfunction: Disaster Preparedness and Planning

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 150	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	150	150
Annual IC Time Burden (Hours)	38	38
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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