Information Collection

3 month follow-up survey

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

Documents and Forms

Documents and forms in this information collection
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

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 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 %

table that charts list of burden
	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

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.