Form J TEACHERS' DATA COLLECTION CHECKLIST

J. Data Collection Checklist for the National Youth Tobacco Survey

	Total # of Students Enrolled in Class *Minus Ineligible Students*	Number of Non Participating Eligible Students (A, ISS, or NFR)**	Number of Student Refusals	Number of Parent Refusals	Number of Completed Surveys
Females
Males
Total

* The following non-participation codes should be used to identify why students are not eligible to participate in the survey (e.g.,other).

Do not include these students in the enrollment totals or on the Make-Up List.

CCI - Cannot Complete Independently	E - Expelled	M - Moved Away
DC - Dropped Class DS - Dropped School	EA - Extended Absence	OSS - Out of School Suspension
	HB - Homebound	TAC - Took in Another Class

***A=Absent; ISS=In School Suspension; NFR=No Form Returned

Please Print

Student Name or Identifier

Gender

(M/F)

Grade

Date Reminder Sent

Check if Permission Form Returned “No”

Check if

Permission Form Returned “Yes”

Eligibility Code (If Student Did NOT Participate)

Eligible for Make-Up?

(yes/no)

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Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road, NE, MS D-74, Atlanta, GA 30333, ATTN:PRA (0920-0621).

Please Print Student Name or Identifier	Gender (M/F)	Grade	Date Reminder Sent	Check if Permission Form Returned “No”	Check if Permission Form Returned “Yes”	Eligibility Code (If Student Did NOT Participate)	Eligible for Make-Up? (yes/no)
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