Information Collection

Youth Baseline Questionnaire (Experimenter and Non-Trier)

IC 208708 under ICR 201506-0910-029 · 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⚠️ Notice: This information collection may be referencing outdated material.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
9 Attachment 6_Youth Assent 0910-0753.doc	Other-Youth Assent
8 Attachment 6_Parent Permission 0910-0753.doc	Other-Parent Permission
12 Attachment 4_Media Tracking Screener and Instrument 0910-0753.doc	Other-Youth Media Tracking Screener
5 Email_reminder1_ 0910-0753.doc	Other-E-mail reminder #1
6 Email_reminder2_ 0910-0753.doc	Other-E-mail reminder #2
7 Email_reminder3_ 0910-0753.doc	Other-E-mail reminder #3
12 Attachment 4_Media Tracking Screener and Instrument 0910-0753.doc	Other-Media Tracking Screener and In

IC Title:

Youth Baseline Questionnaire (Experimenter and Non-Trier)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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-Youth Assent	9 Attachment 6_Youth Assent 0910-0753.doc	Yes	No	Printable Only
Other-Parent Permission	8 Attachment 6_Parent Permission 0910-0753.doc	Yes	No	Printable Only
Other-Youth Media Tracking Screener and Instrument	12 Attachment 4_Media Tracking Screener and Instrument 0910-0753.doc	Yes	No	Printable Only
Other-E-mail reminder #1	5 Email_reminder1_ 0910-0753.doc	Yes	No	Printable Only
Other-E-mail reminder #2	6 Email_reminder2_ 0910-0753.doc	Yes	No	Printable Only
Other-E-mail reminder #3	7 Email_reminder3_ 0910-0753.doc	Yes	No	Printable Only
Other-Media Tracking Screener and Instrument	12 Attachment 4_Media Tracking Screener and Instrument 0910-0753.doc	Yes	No	Printable Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,686

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	2,686	2,686
Annual IC Time Burden (Hours)	1,343	1,343
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.