Form 0920-0621 Data Collection Checklist

Form Approved

OMB No.: 0920-0621

Expiration Date: XX/XX/XXXX

DATA COLLECTION CHECKLIST – NYTS - ACTIVE

State: ______ School Name: __________________________________________ Date of Survey Administration: _______________ Teacher: ___________________________________ Grade(s): ___________ Class: __________________________ Period: ______

Prior to survey administration, please fill out columns 1-5.

This form will be collected by the study representative visiting your school for the National Youth Tobacco Survey (NYTS).

Please use it to track parental permission forms once you have distributed them to students.

Column 1: Please print student name (or identifier) of all students officially on your class roster.

Column 2: Record date permission form reminder sent.

Column 3: For any student who returns the permission form marked “No,” put a check mark.

Column 4: For any student who returns the permission form marked “Yes,” put a check mark.

Column 5: Indicate which, if any, of the codes listed below apply to students officially on your class roster.

CCI – Cannot Complete Independently DS – Dropped School EA – Extended Absence MA – Moved Away

DC – Dropped Class E – Expelled OSS – Out of School Suspension ISS – In School Suspension

Column 6: On the day of survey administration, the study representative will work with you to complete Column 6. You will use the following codes to indicate the reason a student did not participate.  If a code was previously used for a

student, you will not need to indicate another code.

A – Absent NFR – No Permission Form Returned PR – Parent Refusal SR – Student Refusal TAC – Took in Another Class

Column #1 Student Name or Identifier	Column #2 Date Reminder Sent	Column #3 Check if Permission Form was Returned “No”	Column #4 Check if Permission Form was Returned “Yes”	Column #5 Student Codes	Column #6 Student IS Eligible for Make-Up (A, ISS, SR, or NFR only)

Column #1 Student Name or Identifier	Column #2 Date Reminder Sent	Column #3 Check if Permission Form was Returned “No”	Column #4 Check if Permission Form was Returned “Yes”	Column #5 Student Codes	Column #6 Student IS Eligible for Make-Up (A, ISS, SR, or NFR only)

For Office Use Only

Number of Eligible Students	Number of Completed Surveys	Number of Student Refusals (SR)	Number of Parent Refusals (PR)	Number of No Forms Returned (NFR)	Number of Other Non-survey Takers (A, ISS)

Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road, NE, MS D-74, Atlanta, GA 30333, ATTN:PRA