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Covid-19 Impact Survey
The Study to Explore Early Development (SEED) - Phase 3 (Modified for COVID-19 Impact Assessment)
OMB: 0920-1171
IC ID: 244367
OMB.report
HHS/CDC
OMB 0920-1171
ICR 202102-0920-008
IC 244367
( )
Documents and Forms
Document Name
Document Type
Form 0920-21CS
Covid-19 Impact Survey
Form and Instruction
0920-21CS COVID-19 Impact Study, 2020
ITEM #6 Appendix C.3_COV-IMP Survey_11-12_clean.docx
Form and Instruction
0920-21CS COVID-19 Impact Study, 2020
ITEM #6 Appendix C.3_COV-IMP Survey_11-12_clean.docx
Form and Instruction
OMB0920_1171 NonSubstantive Change Request Memo_11-13-2020.docx
Change Request Memo
IC Document
OMB0920_1171 NonSubstantive Change Request Memo_11-13-2020.docx
Change Request Memo
IC Document
OMB 0920-1171 Expedited Review request_.docx
Expedited Review Request
IC Document
OMB 0920-1171 Expedited Review request_.docx
Expedited Review Request
IC Document
OMB0920_1171 NonSubstantive Change_Spanish_1-20-21_final.docx
Change Request
IC Document
OMB0920_1171 NonSubstantive Change_Spanish_1-20-21_final.docx
Change Request
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Covid-19 Impact Survey
Agency IC Tracking Number:
0920-21CS
Is this a Common Form?
No
IC Status:
Modified
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
0920-21CS
COVID-19 Impact Study, 2020
ITEM #6 Appendix C.3_COV-IMP Survey_11-12_clean.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Public Health Monitoring
Privacy Act System of Records
Title:
09-20-0136, Epidemiologic Studies and Surveillance of Disease Problems
FR Citation:
81 FR 9200
Number of Respondents:
1,330
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
1,330
0
0
0
0
1,330
Annual IC Time Burden (Hours)
554
0
0
0
0
554
Annual IC Cost Burden (Dollars)
14,252
0
0
0
0
14,252
Documents for IC
Title
Document
Date Uploaded
Change Request Memo
OMB0920_1171 NonSubstantive Change Request Memo_11-13-2020.docx
12/08/2020
Expedited Review Request
OMB 0920-1171 Expedited Review request_.docx
12/08/2020
Change Request
OMB0920_1171 NonSubstantive Change_Spanish_1-20-21_final.docx
02/18/2021
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.