Information Collection

Multi-Media Project Young Adult Probes

IC 219892 under ICR 201601-0930-004 · OMB 0930-0360.

Documents and Forms

Document Name Document Type
Form Baseline Multi-Media Project Young Adult Probes Form and Instruction
Baseline Baseline Attachment 9_SYAI Baseline.docx Form and Instruction
Follow-up Follow-up Attachment 10_SYAI 12 and 24 Months.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Multi-Media Project Young Adult Probes	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	Baseline	Baseline	Attachment 9_SYAI Baseline.docx		Yes	Yes	Fillable Fileable
Form and Instruction	Follow-up	Follow-up	Attachment 10_SYAI 12 and 24 Months.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 510	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	510	510
Annual IC Time Burden (Hours)	168	168
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.