S4S Informed Assent for Youth

“Talk. They Hear You.”: Use of “Screen 4 Success” Instruments and Consent form

Documents and Forms

Document Name Document Type
Form S4S Informed Assen S4S Informed Assent for Youth Form and Instruction
S4S Informed Assen S4S Informed Assent for Youth Attachment C S4S Informed Assent for Youth.docx Form and Instruction
S4S Informed Assen S4S Informed Assent for Youth Attachment C S4S Informed Assent for Youth.docx Form and Instruction

Information Collection (IC) Details

IC Title:	S4S Informed Assent for Youth	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	S4S Informed Assent for Youth	S4S Informed Assent for Youth	Attachment C S4S Informed Assent for Youth.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: S4S Informed Assent for Youth	FR Citation: 75 FR 28264

Number of Respondents: 100,000	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	100,000	100,000
Annual IC Time Burden (Hours)	4,000	4,000
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.