Information Collection

Appx B_ Parental Permission, Child Assent, and Initial Survey (paper) – Child 7-17 Initial Survey

IC 251056 under ICR 202212-0923-001 · OMB 0923-0064.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0923-0064 Appx B_ Parental Permission, Child Assent, and Initial Survey (paper) – Child 7-17 Initial Survey	Form and Instruction
Form 0923-0064 Parental Permission Form (<18 years of age), Child Assent Form (7 to <18 years), and Initial Child Survey (<18 years of age) Appx B_ Parental Permission, Child Assent, and Initial Survey (paper) – Child 7-17 Initial Survey	Form and Instruction
0923-0064 Parental Permission Form ( P_ApndxB_InChldSrvyAssntPrmssn.docx	Form and Instruction
0923-0064 Parental Permission Form (<18 years of age), Child Assen P_ApndxB_InChldSrvyAssntPrmssn.docx	Form and Instruction

IC Title:

Appx B_ Parental Permission, Child Assent, and Initial Survey (paper) â Child 7-17 Initial Survey

Agency IC Tracking Number:

0923-0064-23BK

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	0923-0064				No		Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Records of Persons Exposed or Potentially Exposed to Hazardous or Toxic Substances (retrievable by name or SSN)

FR Citation: 76 FR 4431

Number of Respondents: 139

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	Previously Approved
Annual Number of Responses for this IC	139	139
Annual IC Time Burden (Hours)	70	70
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.

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