Information Collection

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

IC 213073 under ICR 201801-0920-007 · OMB 0920-1048.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Los Angeles Unified School District School Health Climate and Service Assessment Survey	Form
Los Angeles Schools Assessment Att 7-Screens_LA.docx	Form
Att 4-DataCollect_LA.docx LA School Assessment - Word	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	none	Los Angeles Schools Assessment	Att 7-Screens_LA.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 245

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	245	82	163
Annual IC Time Burden (Hours)	102	34	68
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
LA School Assessment - Word	Att 4-DataCollect_LA.docx	01/29/2018

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