Information Collection

Teen Phone Screener

IC 264293 under ICR 202501-0925-002 · OMB 0925-0781.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Teen Phone Screener	Form
Form 1 Screener Teen Phone Screener	Form
1 Screener Att D - Teen Phone Screener - Revised Sept 2024.docx	Form
1 Screener Att D - Teen Phone Screener - Revised Sept 2024.docx	Form

IC Title:

Teen Phone Screener

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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	1				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 72

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	72	72
Annual IC Time Burden (Hours)	6	6
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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