Head of household questionnaire

Pilot Implementation of the Violence Against Children and Youth Survey (VACS) in the US

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1356 can be found here:

Documents and Forms

Document Name Document Type
Head of household questionnaire Form
Head of household questionnaire AttachmentE_Domestic VACS Head of Household Questionnaire.docx Form

Information Collection (IC) Details

IC Title:	Head of household questionnaire	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	none	Head of household questionnaire	AttachmentE_Domestic VACS Head of Household Questionnaire.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 632	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	632	632
Annual IC Time Burden (Hours)	158	158
Annual IC Cost Burden (Dollars)	4,500	4,500

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.