Information Collection

Youth ages 13-24 in Baltimore City or Garrett County, Maryland (Pre-test 2, rural feasibility pilot, full implementation pilot) Youth Respondent Questionnaire

IC 250663 under ICR 202208-0920-008 · OMB 0920-1356.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-22HW Youth ages 13-24 in Baltimore City or Garrett County, Maryland (Pre-test 2, rural feasibility pilot, full implementation pilot) Youth Respondent Questionnaire	Form and Instruction
0920-22HW DVACS Youth Participant Questionnaire Attachment J_DVACS_Youth Participant Questionnaire.pdf	Form and Instruction
0920-22HW DVACS Youth Participant Questionnaire Attachment J_DVACS_Youth Participant Questionnaire.pdf	Form and Instruction
Attachment J_DVACS_Closing_ Youth Participant Questionnaire_CORE QUESTIONNAIRE CLOSING.pdf Yourh Respondent Questionnaire - Closing	IC Document
Attachment J_DVACS_Closing_ Youth Participant Questionnaire_CORE QUESTIONNAIRE CLOSING.pdf Yourh Respondent Questionnaire - Closing	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Youth ages 13-24 in Baltimore City or Garrett County, Maryland (Pre-test 2, rural feasibility pilot, full implementation pilot) Youth Respondent Questionnaire

Agency IC Tracking Number:

0920-22HW

Is this a Common Form? No

IC Status: Modified

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	0920-22HW	DVACS Youth Participant Questionnaire	Attachment J_DVACS_Youth Participant Questionnaire.pdf		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 377

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	377	377
Annual IC Time Burden (Hours)	377	377
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Yourh Respondent Questionnaire - Closing	Attachment J_DVACS_Closing_ Youth Participant Questionnaire_CORE QUESTIONNAIRE CLOSING.pdf	12/03/2021

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.