Information Collection

Adolescent Screener

IC 228330 under ICR 201708-0910-011 · OMB 0910-0848.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix C_GWL Youth Assent_Clean.docx	Other-Youht Assent
Appendix E_GWL Study Screener_Clean.docx	Other-Study Screener

IC Title:

Adolescent Screener

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
Other-Youht Assent			Appendix C_GWL Youth Assent_Clean.docx		Yes	Yes	Fillable Fileable
Other-Study Screener			Appendix E_GWL Study Screener_Clean.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,432

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	7,432	7,432
Annual IC Time Burden (Hours)	245	245
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.