Information Collection

Adolescent behavior and communication survey consent-assent form

IC 197269 under ICR 201104-0935-003 · OMB 0935-0184.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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
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 %

table that charts list of burden
	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

table that charts IC Documents
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.