Information Collection

Adolescents (Wave Two)

IC 205981 under ICR 201305-0925-001 · OMB 0925-0674.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 4 Adolescents (Wave Two)	Form and Instruction
4 Screen Pre Post Evaluation Attachment 5 - Screen pre post eval.docx	Form and Instruction
5 Screenshots of the Pre Post Evaluation Attachment 8 - Screenshots of Pre Post Evaluations.docx	Form and Instruction

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
Form and Instruction	4	Screen Pre Post Evaluation	Attachment 5 - Screen pre post eval.docx		No	No	Paper Only
Form and Instruction	5	Screenshots of the Pre Post Evaluation	Attachment 8 - Screenshots of Pre Post Evaluations.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

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
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	250	250
Annual IC Time Burden (Hours)	333	333
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.