Information Collection

Youth Baseline Form and Assent

IC 239207 under ICR 202001-0990-001 · OMB 0990-0472.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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
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 %

table that charts list of burden
	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

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.