Information Collection

Web Survey – English

IC 273024 under ICR 202412-0920-005 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Web Survey – English	Form and Instruction
FRAPCE-Formative Research on Adverse & Positive Childhoo Att G FRAPCE Web Survey_English-FINAL for OMB.docx	Form and Instruction
FRAPCE-Formative Research on Adverse & Positive Childhoo Att G FRAPCE Web Survey_English _PHN_final.docx	Form and Instruction
Att G1 Questionnaire screenshots.pdf Questionnaire Screenshots	IC Document

IC Title:

Web Survey â English

Agency IC Tracking Number:

0920-24GO

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	FRAPCE-Formative Research on Adverse & Positive Childhood Experiences Questionnaire	Att G FRAPCE Web Survey_English _PHN_final.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,700

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5,700	5,700
Annual IC Time Burden (Hours)	2,850	2,850
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.