Essentials Instrument and Protocol Evaluation and Surveillance Survey

[NCIPC] Reporting of the Essentials for Childhood (EfC): Preventing Adverse Childhood Experiences through Data to Action Program

Documents and Forms

Document Name Document Type
Form 0920 Essentials Instrument and Protocol Evaluation and Surveillance Survey Form and Instruction
0920 Essentials Instrument and Protocol Evaluation and Survei Att. 6 Evaluation and Surveillance Survey.docx Form and Instruction
0920 Essentials Instrument and Protocol Evaluation and Survei Att. 6 Evaluation and Surveillance Survey.docx Form and Instruction
Att. 6a Evaluation and Surveillance Survey Screenshot.pdf Essentials for Childhood: Preventing ACEs Evaluation and Surveillance Survey IC Document
Att. 6a Evaluation and Surveillance Survey Screenshot.pdf Essentials for Childhood: Preventing ACEs Evaluation and Surveillance Survey IC Document

Information Collection (IC) Details

IC Title:	Essentials Instrument and Protocol Evaluation and Surveillance Survey	Agency IC Tracking Number:	0920-23DT

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 and Instruction	0920	Essentials Instrument and Protocol Evaluation and Surveillance Survey	Att. 6 Evaluation and Surveillance Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 12	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	12	12
Annual IC Time Burden (Hours)	12	12
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Essentials for Childhood: Preventing ACEs Evaluation and Surveillance Survey	Att. 6a Evaluation and Surveillance Survey Screenshot.pdf	10/25/2023

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