Information Collection

It's a Noisy Planet. Protect Their Hearing.® Campaign: Mall Interview Surveys

IC 214692 under ICR 201112-0925-001 · OMB 0925-0648.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0648 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 It's a Noisy Planet. Protect Their Hearing.® Campaign: Mall Interview Surveys	Form and Instruction
1 Adolescent Recruitment Screener and Consent Form NIDCD_NP Screener_Adolescent 1 13 15.docx	Form and Instruction
2 Parent/Guardian Recruitment Screener and Consent Form NIDCD_NP Screener_Parent 1 13 15.docx	Form and Instruction
3 Adolescent Interview Survey NIDCD_NP Survey_Adolescent 12 19 14.docx	Form
4 Parent/Guardian Interview Survey NIDCD_NP Survey_Parent 12 19 14.docx	Form
NIDCD_NP Fast track template 2014(3)[1].docx Noisy Planet Fast-Track Template	IC Document
NIDCD NP Parents Blue Wave Fact Sheet 12 19 14.pdf Parent Blue Wave Fact Sheet	IC Document
NIDCD NP Adolescents Green Wave Fact Sheet 12 19 14.pdf Adolescents Green Wave Fact Sheet	IC Document

IC Title:

It's a Noisy Planet. Protect Their Hearing.Â® Campaign: Mall Interview Surveys

Agency IC Tracking Number:

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	Available Electronically?	Electronic Capability
Form and Instruction	1	Adolescent Recruitment Screener and Consent Form	NIDCD_NP Screener_Adolescent 1 13 15.docx	No	Paper Only
Form and Instruction	2	Parent/Guardian Recruitment Screener and Consent Form	NIDCD_NP Screener_Parent 1 13 15.docx	No	Paper Only
Form	3	Adolescent Interview Survey	NIDCD_NP Survey_Adolescent 12 19 14.docx	No	Paper Only
Form	4	Parent/Guardian Interview Survey	NIDCD_NP Survey_Parent 12 19 14.docx	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 86

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	86	86
Annual IC Time Burden (Hours)	29	29
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Noisy Planet Fast-Track Template	NIDCD_NP Fast track template 2014(3)[1].docx	01/20/2015
Parent Blue Wave Fact Sheet	NIDCD NP Parents Blue Wave Fact Sheet 12 19 14.pdf	01/20/2015
Adolescents Green Wave Fact Sheet	NIDCD NP Adolescents Green Wave Fact Sheet 12 19 14.pdf	01/20/2015

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