Information Collection

Multi-Media Project Young Adult Probes

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

Documents and Forms

Documents and forms in this information collection
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

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	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 %

table that charts list of burden
	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

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.