Information Collection

Online Screening Instrument for Youth

IC 188375 under ICR 201009-0920-001 · OMB 0920-0816.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att.H -- Online Survey Screening Instrument for Youth_final_1-26-09.doc	Other-WORD
Att.I -- Online Survey Youth Assent Form v3_final_1-26-09.doc Att	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-WORD			Att.H -- Online Survey Screening Instrument for Youth_final_1-26-09.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 %

table that charts list of burden
	Approved	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

table that charts IC Documents
Title	Document	Date Uploaded
Att	Att.I -- Online Survey Youth Assent Form v3_final_1-26-09.doc	02/02/2009

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