Online Screening Instrument for Youth

Youth Advice and Feedback to Inform Choose Respect Implementation

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0816 can be found here:

Documents and Forms

Document Name Document Type
Attach H Online Survey Screening Instrument for Youth REV 1-09 REV 4-28-10.doc Other-Word
Attach I Online Survey Youth Assent Form REV 1-9-09.doc Attach I Online Survey Youth Assent Form REV 1-9-09 IC Document

Information Collection (IC) Details

IC Title:	Online Screening Instrument for Youth	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Word			Attach H Online Survey Screening Instrument for Youth REV 1-09 REV 4-28-10.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 400	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Previously Approved
Annual Number of Responses for this IC	1,600	1,600
Annual IC Time Burden (Hours)	80	80
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attach I Online Survey Youth Assent Form REV 1-9-09	Attach I Online Survey Youth Assent Form REV 1-9-09.doc	06/30/2010

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