Information Collection

Att 3_Sample Instrument: Youth Questionnaire

IC 231024 under ICR 201804-0920-006 · OMB 0920-1235.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1235 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-xxxx Att 3_Sample Instrument: Youth Questionnaire	Form and Instruction
0920-xxxx Sample Instrument: Youth Questionnaire Att 3-Sample Instrument-Youth Questionnaire.docx	Form and Instruction

IC Title:

Att 3_Sample Instrument: Youth Questionnaire

Agency IC Tracking Number:

0920-18AF

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	0920-xxxx	Sample Instrument: Youth Questionnaire	Att 3-Sample Instrument-Youth Questionnaire.docx		No		Fillable Fileable Signable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 20,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 25 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	20,000	20,000
Annual IC Time Burden (Hours)	16,667	16,667
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.