Information Collection

Youth Activity Diary

IC 203635 under ICR 201208-0920-003 · OMB 0920-0977.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0977 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Youth Activity Diary	Form
Youth Activity Diary Att 13C_Youth Activity Diary.docx	Form
Spanish Youth Activity Diary Att S13C_Youth Diary Spanish.docx	Form

IC Title:

Youth Activity Diary

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	none	Youth Activity Diary	Att 13C_Youth Activity Diary.docx		Yes	No	Printable Only
Form	none	Spanish Youth Activity Diary	Att S13C_Youth Diary Spanish.docx		Yes	No	Printable Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title: Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 250

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	250	250
Annual IC Time Burden (Hours)	42	42
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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