Information Collection

Screener (Parent)

IC 208786 under ICR 201309-0930-002 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Focus Group Screen Screener (Parent)	Form and Instruction
Focus Group Screen Focus Group Screener Attachment A - Focus Group Screener.docx	Form and Instruction
Attachment H - Trevor Comments - SAMHSA Tobacco - 09-13 -13.pdf Comment	IC Document
Attachment F - Parent Consent Form.doc Parental Consent Form	IC Document
Attachment D - Project Design.docx Project Design	IC Document

IC Title:

Screener (Parent)

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 and Instruction	Focus Group Screener	Focus Group Screener	Attachment A - Focus Group Screener.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 576

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	576	576
Annual IC Time Burden (Hours)	86	86
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Comment	Attachment H - Trevor Comments - SAMHSA Tobacco - 09-13 -13.pdf	09/23/2013
Parental Consent Form	Attachment F - Parent Consent Form.doc	09/23/2013
Project Design	Attachment D - Project Design.docx	09/23/2013

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