Adolescent Pre-Focus Group Interview Script

Evaluation of the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) Quality Demonstration Grant Program

Documents and Forms

Document Name Document Type
Form 15 Adolescent Pre-Focus Group Interview Script Form and Instruction
15 Adolescent Pre-Focus Group Interview Script Attachment S- 2014 Adolescent Pre-Focus Group Interview Script.docx Form and Instruction
Attachment Q- 2014 Adolescent Focus Group Recruitment Materials.docx Attachment Q- 2014 Adolescent Focus Group Recruitment Materials IC Document

Information Collection (IC) Details

IC Title:	Adolescent Pre-Focus Group Interview Script	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	15	Adolescent Pre-Focus Group Interview Script	Attachment S- 2014 Adolescent Pre-Focus Group Interview Script.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 40	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 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	13	13
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.