Student Effectiveness Baseline Survey

Evaluation of the Safe Dates Project

Documents and Forms

Document Name Document Type
Attachment L - Youth Dating Survey.docx Other-WORD
Attachment I - Safe Dates Student Assent.docx Attachment I - Safe Dates Student Assent IC Document
Attachment H - Parent Brochure.docx Attachment H - Parent Brochure IC Document
Attachment D - Student Privacy Pledge.doc Attachment D - Student Privacy Pledge IC Document

Information Collection (IC) Details

IC Title:	Student Effectiveness Baseline Survey	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			Attachment L - Youth Dating Survey.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10,158	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	10,158	10,158
Annual IC Time Burden (Hours)	5,926	5,926
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment I - Safe Dates Student Assent	Attachment I - Safe Dates Student Assent.docx	09/23/2010
Attachment H - Parent Brochure	Attachment H - Parent Brochure.docx	09/23/2010
Attachment D - Student Privacy Pledge	Attachment D - Student Privacy Pledge.doc	09/23/2010

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