Information Collection

3 month follow-up survey

IC 239210 under ICR 202001-0990-001 · OMB 0990-0472.

Documents and Forms

Document Name Document Type
Form 5 3 month follow-up survey Form and Instruction
5 3 month follow-up youth survey Appendix E_MITRE Pregnancy Prevention Youth Survey Follow-Up Instrument_clean.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	3 month follow-up survey	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	5	3 month follow-up youth survey	Appendix E_MITRE Pregnancy Prevention Youth Survey Follow-Up Instrument_clean.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 876	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	876	876
Annual IC Time Burden (Hours)	730	730
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.