Youth Baseline Form and Assent

Evaluation of Pregnancy Prevention Program Replications for High Risk and Hard to Reach Youth

Documents and Forms

Document Name Document Type
Form 3 Youth Baseline Form and Assent Form
3 Youth baseline survey Appendix D_MITRE Pregnancy Prevention Youth Survey Baseline Instrument_clean.docx Form
2 Youth Assent Form for Youth Survey Appendix C_Youth Assent Page for Surveys.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Youth Baseline Form and Assent	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	3	Youth baseline survey	Appendix D_MITRE Pregnancy Prevention Youth Survey Baseline Instrument_clean.docx		Yes	Yes	Fillable Fileable
Form and Instruction	2	Youth Assent Form for Youth Survey	Appendix C_Youth Assent Page for Surveys.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,163	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,163	4,163
Annual IC Time Burden (Hours)	1,041	1,041
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.