Information Collection

Essentials Instrument and Protocol Evaluation and Surveillance Survey

IC 262777 under ICR 202507-0920-007 · OMB 0920-1425.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920 Essentials Instrument and Protocol Evaluation and Surveillance Survey	Form and Instruction
Form 0920 Essentials Instrument and Protocol Evaluation and Surveillance Survey Essentials Instrument and Protocol Evaluation and Surveillance Survey	Form and Instruction
Form 0920-1425 Essentials Instrument and Protocol Evaluation and Surveillance Survey - Revised 10JUL2025 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
0920-1425 Essentials Instrument and Protocol Evaluation and Survei Att. 6 Evaluation and Surveillance Survey 050125 clean.docx	Form and Instruction
0920-1425 Essentials Instrument and Protocol Evaluation and Survei Att. 6 Evaluation and Surveillance Survey 050125 clean.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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	0920				Yes	Yes	Fillable Fileable
Form and Instruction	0920-1425			N/A	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 %

table that charts list of burden
	Approved	Previously Approved
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

table that charts IC Documents
Title	Document	Date Uploaded
Essentials for Childhood: Preventing ACEs Evaluation and Surveillance Survey		10/25/2023

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

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