Information Collection

Health Center Youth Survey

IC 222373 under ICR 201912-0920-012 · OMB 0920-1156.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Health Center Youth Survey	Form and Instruction
Helath Center Youth Survey Att 6 Health Center Youth Survey_6 22 2016.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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	NA	Helath Center Youth Survey	Att 6 Health Center Youth Survey_6 22 2016.docx	NA	No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,050

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	-1,050	1,050
Annual IC Time Burden (Hours)	-175	175
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.