DGA 2010 Formative Research to Inform Public

Generic Clearance to Conduct Formative Research/CNPP

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0584-0523 can be found here:

Documents and Forms

Document Name Document Type
ATTACHMENT B informed consent form 12.2.10.doc www.knowledgenetworks.org Other-Parental Consent Form
Attachment_D v2_Adult_Survey 12 2 10.pdf www.knowledgenetworks.org Other-Adult Survey
Attachment E Youth Survey12 2 10.pdf www.knowledgenetworks.org Other-Kids Survey
OMB Justification 11-16-10.docx OMB Justification IC Document
Attachment C Privacy Statement 11-16-10.docx Privacy Statement IC Document
Attachment A Invitation.docx Invitation Letter IC Document
OMB Justification 12 2 10 Revised.docx Final - OMB Justification IC Document
Attachment C Privacy Statement11.12.10.FINAL.docx Final - Privacy Statement IC Document

Information Collection (IC) Details

IC Title:	DGA 2010 Formative Research to Inform Public	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Adult Survey	Attachment_D v2_Adult_Survey 12 2 10.pdf	www.knowledgenetworks.org	Yes	Yes	Fillable Fileable Signable
Other-Kids Survey	Attachment E Youth Survey12 2 10.pdf	www.knowledgenetworks.org	Yes	Yes	Fillable Fileable Signable
Other-Parental Consent Form	ATTACHMENT B informed consent form 12.2.10.doc	www.knowledgenetworks.org	Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,075	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5,075	5,075
Annual IC Time Burden (Hours)	2,065	2,065
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
OMB Justification	OMB Justification 11-16-10.docx	11/16/2010
Privacy Statement	Attachment C Privacy Statement 11-16-10.docx	11/16/2010
Invitation Letter	Attachment A Invitation.docx	11/18/2010
Final - OMB Justification	OMB Justification 12 2 10 Revised.docx	12/06/2010
Final - Privacy Statement	Attachment C Privacy Statement11.12.10.FINAL.docx	12/06/2010

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