Adolescent Survey - Adolescent 13-17 years of age

Traumatic Brain Injury (TBI) Surveillance System

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1240 can be found here:

Documents and Forms

Document Name Document Type
Adolescent Survey - Adolescent 13-17 years of age Form and Instruction
Adolescent Survey - English E-5 Adolescent Survey - English.docx Form and Instruction
Adolescent Survey - Spanish E-11 Adolescent Survey -- Spanish.docx Form and Instruction
Adolescent Survey (Web version) - English E-6 Adolescent Survey (web) -- English.docx Form and Instruction
Adolescent Survey (Web version) - Spanish E-12 Adolescent Survey (web) -- Spanish.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Adolescent Survey - Adolescent 13-17 years of age	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	NA	Adolescent Survey - English	E-5 Adolescent Survey - English.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	Adolescent Survey - Spanish	E-11 Adolescent Survey -- Spanish.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	Adolescent Survey (Web version) - English	E-6 Adolescent Survey (web) -- English.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	Adolescent Survey (Web version) - Spanish	E-12 Adolescent Survey (web) -- Spanish.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 180	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	180	180
Annual IC Time Burden (Hours)	45	45
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.