Information Collection

[NCIPC] Adverse Childhood Experiences Prevention Message Development

IC 270987 under ICR 202503-0920-028 · OMB 0920-1154.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1154 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1154 [NCIPC] Adverse Childhood Experiences Prevention Message Development	Form and Instruction
Form 0920-1154 ACEs Survey and Consent - Revised 25MAR2025 [NCIPC] Adverse Childhood Experiences Prevention Message Development	Form and Instruction
Form 0920-1154 ACEs Focus Group Participant Screener - Revised 25MAR2025 [NCIPC] Adverse Childhood Experiences Prevention Message Development	Form and Instruction
Form 0920-1154 (24IP) ACEs Focus Group Consent Form [NCIPC] Adverse Childhood Experiences Prevention Message Development	Form and Instruction
Form 0920-1154 (24IP) ACEs Partner Interview Consent Form [NCIPC] Adverse Childhood Experiences Prevention Message Development	Form and Instruction
Form 0920-1154 (24IP) ACEs Partner Interview Guide [NCIPC] Adverse Childhood Experiences Prevention Message Development	Form and Instruction
Att 2. ACEs Survey Screenshots_8.7.24ka.docx	Other-Screenshots
Att 2. ACEs Survey Screenshots_8.7.24ka.docx	Other-Screenshots
Att 5. ACEs Focus Group Guide_v2.docx	Instruction
Att 5. ACEs Focus Group Guide_v2.docx	Instruction
0920-1154 ACEs Survey and Consent - Revised 25MAR2025 Att 1. ACEs Survey and Consent__OMB Edited 12.2.24.docx	Form and Instruction
0920-1154 ACEs Survey and Consent - Revised 25MAR2025 Att 1. ACEs Survey and Consent__OMB Edited 12.2.24.docx	Form and Instruction
0920-1154 ACEs Focus Group Participant Screener - Revised 25MAR202 Att 3. ACEs Focus Group Participant Screener_OMB Edited12.2.24.docx	Form and Instruction
0920-1154 ACEs Focus Group Participant Screener - Revised 25MAR202 Att 3. ACEs Focus Group Participant Screener_OMB Edited12.2.24.docx	Form and Instruction
0920-1154 (24IP) ACEs Focus Group Consent Form Att 4. ACEs Focus Group Consent_v3.docx	Form and Instruction
0920-1154 (24IP) ACEs Focus Group Consent Form Att 4. ACEs Focus Group Consent_v3.docx	Form and Instruction
0920-1154 (24IP) ACEs Partner Interview Consent Form Att 6. ACEs Partner Interview Consent Form_v3.docx	Form and Instruction
0920-1154 (24IP) ACEs Partner Interview Consent Form Att 6. ACEs Partner Interview Consent Form_v3.docx	Form and Instruction
0920-1154 (24IP) ACEs Partner Interview Guide Att 7. ACEs Partner Interview Guide_v2.docx	Form and Instruction
0920-1154 (24IP) ACEs Partner Interview Guide Att 7. ACEs Partner Interview Guide_v2.docx	Form and Instruction
ACE Prevention Message SSA_OMB Corrected 12.02.24.docx SSA (24IP)	IC Document
ACE Prevention Message SSA_OMB Corrected 12.02.24.docx SSA (24IP)	IC Document
ACE Prevention Message SSB__8.7.24ka.docx SSB (24IP)	IC Document
ACE Prevention Message SSB__8.7.24ka.docx SSB (24IP)	IC Document
Att 8. ACEs Messages for Testing_v1.docx ACEs Messages for Testing (24IP)	IC Document
Att 8. ACEs Messages for Testing_v1.docx ACEs Messages for Testing (24IP)	IC Document
Att 10. ACEs Non-Research determination.docx Project Determination (24IP)	IC Document
Att 10. ACEs Non-Research determination.docx Project Determination (24IP)	IC Document
ACE Prevention Message SSB_tracked changes.docx Revised Supporting Statement B 25MAR2025	IC Document
ACE Prevention Message SSB_tracked changes.docx Revised Supporting Statement B 25MAR2025	IC Document
ACEs_0920-1154_Change Request Memo - EO14168.docx Change Request Memo 25MAR2025	IC Document
ACEs_0920-1154_Change Request Memo - EO14168.docx Change Request Memo 25MAR2025	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

[NCIPC] Adverse Childhood Experiences Prevention Message Development

Agency IC Tracking Number:

0920-1154-24IP

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-1154	N/A	Yes	Yes	Fillable Fileable
Other-Screenshots			No		Printable Only
Form and Instruction	0920-1154	N/A	Yes	Yes	Fillable Fileable
Form and Instruction	0920-1154 (24IP)		Yes	Yes	Fillable Fileable
Instruction			Yes	Yes	Fillable Fileable
Form and Instruction	0920-1154 (24IP)		Yes	Yes	Fillable Fileable
Form and Instruction	0920-1154 (24IP)		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 200

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	86	86
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA (24IP)		12/11/2024
SSB (24IP)		09/17/2024
ACEs Messages for Testing (24IP)		09/17/2024
Project Determination (24IP)		09/17/2024
Revised Supporting Statement B 25MAR2025		03/25/2025
Change Request Memo 25MAR2025		03/25/2025

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

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