Information Collection

Youth Survey

IC 203637 under ICR 201305-0920-002 · OMB 0920-0977.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Youth Survey	Form
Youth Survey Att 9B_YouthSurvey.docx	Form
Youth Survey - Spanish Att 9B-S_YouthSurvey_SP.docx	Form
Att 9C_Youth_CaregiverSurvey_ItemSources_2013_0618.pdf Att 9C_Youth_CaregiverSurvey_ItemSources_2013_0618	IC Document

IC Title:

Youth Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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 Survey	Att 9B_YouthSurvey.docx		Yes	Yes	Fillable Fileable
Form	none	Youth Survey - Spanish	Att 9B-S_YouthSurvey_SP.docx		Yes	Yes	Fillable Fileable

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: 640

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	640	640
Annual IC Time Burden (Hours)	213	213
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 9C_Youth_CaregiverSurvey_ItemSources_2013_0618	Att 9C_Youth_CaregiverSurvey_ItemSources_2013_0618.pdf	08/06/2013

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