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OMB No. 0980-0229
Expiration Date: 05/31/00
NATIONAL CHILD ABUSE AND NEGLECT DATA
SYSTEM
Summary Data Component Survey
1997 Data Year
CONTACT INFORMATION
| Submission Year | [ | ] | |
| State/Territory | [ | ] |
Reporting Year: Respond with either Y for "yes" or N for "no" for both Fiscal and Calendar Year.
| Calendar Year Fiscal Year |
[ [ |
] ] |
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| Contact Information: | |||
| Name | [ | ] | |
| Title | [ | ] | |
| Address | [ [ [ |
] ] ] |
|
| Phone | [ | ] | |
| FAX | [ | ] | |
| [ | ] |
