Form Approved
OMB No. 0920-xxxx
Expiration Date: xx/xx/xxxx
2021 and 2023 National Youth Risk Behavior Survey
Attachment G
Data Collection Checklist
Form Approved OMB No.: 0920-xxxx Expiration Date: xx/xx/xxxx Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the 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: OMB-PRA (0920-xxxx)
DATA COLLECTION CHECKLIST 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 Risk Behavior Survey (YRBS).
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
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Column #1 Student Name or Identifier |
Column #2 Date Reminder Sent |
Column #3
Form was Returned “No” |
Column #4
Form was Returned “Yes” |
Column #5 Student Codes |
Column #6
(A, ISS, SR, or NFR only) |
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Column #1 Student Name or Identifier |
Column #2 Date Reminder Sent |
Column #3
Form was Returned “No” |
Column #4
Form was Returned “Yes” |
Column #5 Student Codes |
Column #6
(A, ISS, SR, or NFR only) |
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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 Form Returned (NFR) |
Number of Other Non-Survey Takers (A, ISS) |
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | DATA COLLECTION CHECKLIST |
Author | MACRO |
File Created | 2024:12:23 00:01:05Z |