Information Collection

Screener (Youth)

IC 208787 under ICR 201309-0930-002 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Youth Assent Form Screener (Youth)	Form and Instruction
Youth Assent Form Youth Assent Form Attachment G - Youth Assent Form.doc	Form and Instruction
Focus Group Modera Focus Group Moderator's Guide Attachment A - Focus Group Screener.docx	Form and Instruction

IC Title:

Screener (Youth)

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	Youth Assent Form	Youth Assent Form	Attachment G - Youth Assent Form.doc		Yes	Yes	Fillable Printable
Form and Instruction	Focus Group Moderator's Guide	Focus Group Moderator's Guide	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: 144

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	144	144
Annual IC Time Burden (Hours)	22	22
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.