Adolescent behavior and communication survey consent-assent form

Connecting Primary Care Practices with Hard-to-Reach Adolescent Populations

Documents and Forms

Document Name Document Type
Form Form #3 Adolescent behavior and communication survey consent-assent form Form and Instruction
Form #3 Adolescent behavior and communication survey consent-ass Attachment E -- Adolescent Behavior and Communication Survey Consent-Assent.doc Form and Instruction
Attachment D -- Adolescent Behavior and Communication Survey Information Letter.doc Attachment D -- Adolescent Behavior and Communication Survey Information Letter IC Document

Information Collection (IC) Details

IC Title:	Adolescent behavior and communication survey consent-assent form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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
Form and Instruction	Form #3	Adolescent behavior and communication survey consent-assent form	Attachment E -- Adolescent Behavior and Communication Survey Consent-Assent.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 776	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	776	776
Annual IC Time Burden (Hours)	194	194
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment D -- Adolescent Behavior and Communication Survey Information Letter	Attachment D -- Adolescent Behavior and Communication Survey Information Letter.doc	03/30/2011

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