Information Collection

DGA 2010 Formative Research to Inform Public

IC 195224 under ICR 200910-0584-002 · OMB 0584-0523.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.