Information Collection

Adolescent Telephone Screening Script

IC 210513 under ICR 201402-0935-001 · OMB 0935-0190.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 14 Adolescent Telephone Screening Script	Form and Instruction
14 Adolescent Telephone Screening Script Attachment R- 2014 Adolescent Telephone Screening Script.docx	Form and Instruction
Attachment Q- 2014 Adolescent Focus Group Recruitment Materials.docx Attachment Q- 2014 Adolescent Focus Group Recruitment Materials	IC Document

IC Title:

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	14	Adolescent Telephone Screening Script	Attachment R- 2014 Adolescent Telephone Screening Script.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 57

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

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	57	57
Annual IC Time Burden (Hours)	5	5
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment Q- 2014 Adolescent Focus Group Recruitment Materials	Attachment Q- 2014 Adolescent Focus Group Recruitment Materials.docx	02/19/2014

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