Information Collection

Adult/Caregiver Survey

IC 249756 under ICR 202110-0920-002 · OMB 0920-1362.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Adult/Caregiver Survey	Form and Instruction
Parent Survey of Health 2021 Att 11 Parent Caregiver Survey.docx	Form and Instruction
Parent Survey of Health 2021 Att 11 Parent Caregiver Survey.docx	Form and Instruction
Att 3 TAPS Parent Survey Screenshots.docx Screenshots	IC Document
Att 3 TAPS Parent Survey Screenshots.docx Screenshots	IC Document

IC Title:

Agency IC Tracking Number:

0920-21GA

Is this a Common Form? No

IC Status: New

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 and Instruction	N/A	Parent Survey of Health 2021	Att 11 Parent Caregiver Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,634

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 95 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,634	2,634
Annual IC Time Burden (Hours)	878	878
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Screenshots	Att 3 TAPS Parent Survey Screenshots.docx	10/15/2021

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