Youth participant 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⚠️ Notice: This information collection may be referencing outdated material.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
Youth participant questionnaire Form
Youth participant questionnaire AttachmentJ_VACS Youth Participant Questionnaire_EFtracked.docx Form
AttachmentK_Screeneshots.pdf Questionnaire screenshots IC Document

Information Collection (IC) Details

IC Title:	Youth participant 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	Youth participant questionnaire	AttachmentJ_VACS Youth Participant Questionnaire_EFtracked.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 377	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	377	377
Annual IC Time Burden (Hours)	377	377
Annual IC Cost Burden (Dollars)	10,741	10,741

Documents for IC

Title	Document	Date Uploaded
Questionnaire screenshots	AttachmentK_Screeneshots.pdf	12/21/2020

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