Information Collection

Caregiver Survey

IC 270639 under ICR 202409-0920-002 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-23IE Caregiver Survey	Form
0920-23IE Caregiver Survey_English Attachment 4a cover sheet_Caregiver Survey_online_English.docx	Form
0920-23IE Caregiver Survey_online_Spanish Attachment 4c cover sheet_Caregiver Survey_online_Spanish.docx	Form
Attachment 4b cover sheet_Caregiver Survey_paper_English.docx Caregiver Survey_paper_English	IC Document
Attachment 4d cover sheet_Caregiver Survey_paper_Spanish.docx Caregiver Survey_paper_Spanish	IC Document
Attachment 4e cover sheet_Caregiver Survey consent form.docx Caregiver Survey consent form	IC Document
Attachment 4f cover sheet_Caregiver Survey consent form_Spanish.docx Caregiver Survey consent form_Spanish	IC Document
Attachment 4g cover sheet_Caregiver Survey recruitment communications.docx Caregiver Survey recruitment communications	IC Document
Attachment 4h cover sheet_Caregiver Survey recruitment communications_Spanish.docx Caregiver Survey recruitment communications_Spanish	IC Document

IC Title:

Caregiver Survey

Agency IC Tracking Number:

0920-23IE

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	0920-23IE	Caregiver Survey_English	Attachment 4a cover sheet_Caregiver Survey_online_English.docx		Yes	Yes	Fillable Fileable
Form	0920-23IE	Caregiver Survey_online_Spanish	Attachment 4c cover sheet_Caregiver Survey_online_Spanish.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 900

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	900	900
Annual IC Time Burden (Hours)	225	225
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Caregiver Survey_paper_English	Attachment 4b cover sheet_Caregiver Survey_paper_English.docx	09/05/2024
Caregiver Survey_paper_Spanish	Attachment 4d cover sheet_Caregiver Survey_paper_Spanish.docx	09/05/2024
Caregiver Survey consent form	Attachment 4e cover sheet_Caregiver Survey consent form.docx	09/05/2024
Caregiver Survey consent form_Spanish	Attachment 4f cover sheet_Caregiver Survey consent form_Spanish.docx	09/05/2024
Caregiver Survey recruitment communications	Attachment 4g cover sheet_Caregiver Survey recruitment communications.docx	09/05/2024
Caregiver Survey recruitment communications_Spanish	Attachment 4h cover sheet_Caregiver Survey recruitment communications_Spanish.docx	09/05/2024

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