Information Collection

Media Tracking Questionnaires 1st, 2nd and; 3rd

IC 208714 under ICR 201502-0910-009 · OMB 0910-0753.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0910-0753 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
12 Attachment 4_Media Tracking Screener and Instrument 0910-0753.doc	Other-Media Tracking Screener and In
13 Rationale for Item Changes to the ExPECTT Media Tracking Instrument 0901-0753.docx	Other-Rationale for Item Changes to
10 Attachment 2_Youth Follow-up Instrument 0910-0753.doc	Other-Youth Follow up Instrument
11 Rationale for Item Changes to the Follow Up Instrument 0910-0753.docx	Other-Rational for Item Changes to t
0 Contents of OMB Change Request for ExPECTT Second Follow Up.doc Contents of change request	IC Document

IC Title:

Media Tracking Questionnaires 1st, 2nd and; 3rd

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	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Media Tracking Screener and Instrument	12 Attachment 4_Media Tracking Screener and Instrument 0910-0753.doc	Yes	No	Printable Only
Other-Rationale for Item Changes to Media Tracking Instrument	13 Rationale for Item Changes to the ExPECTT Media Tracking Instrument 0901-0753.docx	Yes	No	Printable Only
Other-Youth Follow up Instrument	10 Attachment 2_Youth Follow-up Instrument 0910-0753.doc	Yes	No	Printable Only
Other-Rational for Item Changes to the Follow up Instrument	11 Rationale for Item Changes to the Follow Up Instrument 0910-0753.docx	Yes	No	Printable Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,999

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	3,999	3,999
Annual IC Time Burden (Hours)	2,001	2,001
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Contents of change request	0 Contents of OMB Change Request for ExPECTT Second Follow Up.doc	03/04/2015

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