Information Collection

Participant Screener and Recruitment Form

IC 200324 under ICR 201305-0920-007 · OMB 0920-0915.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att 5_Screener & Script.docx	Other-WORD
SUPPLEMENTAL1_Permission Form for Parents of Adolescents Ages 15-17 (100511 (2).docx SUPPLEMENTAL1_Permission Form for Parents of Adolescents Ages 15-17 (100511 (2)	IC Document
SUPPLEMENTAL2_Assent for Adolescents Aged 15-17 (100511) (2).docx SUPPLEMENTAL2_Assent for Adolescents Aged 15-17 (100511) (2)	IC Document
SUPPLEMENTAL3_ Informed Consent for Adults (100511) (2).docx SUPPLEMENTAL3_ Informed Consent for Adults (100511) (2)	IC Document

IC Title:

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
Other-WORD			Att 5_Screener & Script.docx		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 120

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	120	120
Annual IC Time Burden (Hours)	24	24
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SUPPLEMENTAL1_Permission Form for Parents of Adolescents Ages 15-17 (100511 (2)	SUPPLEMENTAL1_Permission Form for Parents of Adolescents Ages 15-17 (100511 (2).docx	05/10/2013
SUPPLEMENTAL2_Assent for Adolescents Aged 15-17 (100511) (2)	SUPPLEMENTAL2_Assent for Adolescents Aged 15-17 (100511) (2).docx	05/10/2013
SUPPLEMENTAL3_ Informed Consent for Adults (100511) (2)	SUPPLEMENTAL3_ Informed Consent for Adults (100511) (2).docx	05/10/2013

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