2013 YRBS - Data Collection Checklist

I. Data Collection Checklist for the Youth Risk Behavior Survey

Form Approved

OMB No.: 0920-0493

Expiration Date: XX/XX/XXXX

DATA COLLECTION CHECKLIST – YRBS - ACTIVE

School Name: ____________________________________________ Date of Survey Administration: _____________________ Teacher: __________________________________ Grade(s): _____ Class: ______________________ Period: ______

	Total Number of Students Enrolled in Class Minus Ineligible* Students	Number of Non Participating Eligible Students (Code as A – Absent; ISS - In School Suspension; SR – Student Refusal; or NFR – No Form Returned)				Number of Parent Refusals (PR)	Number of Completed Surveys
		A	ISS	SR	NFR
Females
Males
Total

* The following non-participation codes should be used to identify why students are not eligible to participate in the survey. Do not include these students in the enrollment totals or on the Make-Up List.

CCI – Cannot Complete Independently DS – Dropped School EA – Extended Absence MA – Moved Away TAC – Took in Another Class

DC – Dropped Class E – Expelled H – Homebound OSS – Out of School Suspension

Please Print

Student Name or Identifier

Gender

(M/F)

Grade

Date Reminder Sent

Check if Permission

Form was Returned

“No”

Check if Permission

Form was Returned “Yes”

If Student Did NOT Participate

Record Eligibility Code

If Eligibility Code is:

A, ISS, SR

or NFR

• Student IS Eligible for Make-Up

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Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road, NE, MS D-74, Atlanta, GA 30333, ATTN:PRA (0920-0493).

Please Print Student Name or Identifier	Gender (M/F)	Grade	Date Reminder Sent	Check if Permission Form was Returned “No”	Check if Permission Form was Returned “Yes”	If Student Did NOT Participate Record Eligibility Code	If Eligibility Code is: A, ISS, SR or NFR Student IS Eligible for Make-Up
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