Head of Household (Pre-test 2, rural feasibility pilot in Garrett County, full implementation pilot in Baltimore City) Screener Questionnaire

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

Documents and Forms

Document Name Document Type
Form 0920-22HW Head of Household (Pre-test 2, rural feasibility pilot in Garrett County, full implementation pilot in Baltimore City) Screener Questionnaire Form and Instruction
0920-22HW Screening Questionnaire Attachment I_Screener Questionnaire.docx Form and Instruction
0920-22HW Screening Questionnaire Attachment I_Screener Questionnaire.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Head of Household (Pre-test 2, rural feasibility pilot in Garrett County, full implementation pilot in Baltimore City) Screener Questionnaire	Agency IC Tracking Number:	0920-22HW

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	0920-22HW	Screening Questionnaire	Attachment I_Screener 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: 2,808	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	2,808	2,808
Annual IC Time Burden (Hours)	140	140
Annual IC Cost Burden (Dollars)	0	0

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.