Information Collection

[NCIPC] Adolescent Mental Health Journey Mapping Project

IC 269522 under ICR 202503-0920-028 · OMB 0920-1154.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1154 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Screening Survey and Parental Consent [NCIPC] Adolescent Mental Health Journey Mapping Project	Form and Instruction
LGBTQ+ Teen Screening Survey [NCIPC] Adolescent Mental Health Journey Mapping Project	Form and Instruction
Adolescent Interview Discussion Guide [NCIPC] Adolescent Mental Health Journey Mapping Project	Form and Instruction
Adolescent Focus Group Discussion Guide [NCIPC] Adolescent Mental Health Journey Mapping Project	Form and Instruction
Adolescent Brainstorming Session Discussion Guide [NCIPC] Adolescent Mental Health Journey Mapping Project	Form and Instruction
Attachment 1_Email.docx	Instruction
Attachment 1_Email.docx	Instruction
Attachment 3_Consent.AssentForms.docx	Other-Consent/Assent Forms
Attachment 3_Consent.AssentForms.docx	Other-Consent/Assent Forms
Screening Survey and Parental Consent Attachment 2_Screening Survey.docx	Form and Instruction
Screening Survey and Parental Consent Attachment 2_Screening Survey.docx	Form and Instruction
LGBTQ+ Teen Screening Survey Attachment 2a_LGBTQ_Screening Survey.docx	Form and Instruction
LGBTQ+ Teen Screening Survey Attachment 2a_LGBTQ_Screening Survey.docx	Form and Instruction
Adolescent Interview Discussion Guide Attachment 4_Adolescent Interview Discussion Guides.docx	Form and Instruction
Adolescent Interview Discussion Guide Attachment 4_Adolescent Interview Discussion Guides.docx	Form and Instruction
Adolescent Focus Group Discussion Guide Attachment 5_Adolescent Focus Group Discussion Guides.docx	Form and Instruction
Adolescent Focus Group Discussion Guide Attachment 5_Adolescent Focus Group Discussion Guides.docx	Form and Instruction
Adolescent Brainstorming Session Discussion Guide Attachment 6_ Adolescent Brainstorming Session Discussion Guide.docx	Form and Instruction
Adolescent Brainstorming Session Discussion Guide Attachment 6_ Adolescent Brainstorming Session Discussion Guide.docx	Form and Instruction
AMH Formative Research SSA_Teens_4.19.24_final.docx SSA	IC Document
AMH Formative Research SSA_Teens_4.19.24_final.docx SSA	IC Document
AMH Formative Research SSB_Teens_4.19.24.docx SSB	IC Document
AMH Formative Research SSB_Teens_4.19.24.docx SSB	IC Document
Attachment 7_PIA Form_AMH_06.04.24.pdf PIA	IC Document
Attachment 7_PIA Form_AMH_06.04.24.pdf PIA	IC Document
Attachment 8_IRB Approval.pdf Research Determination	IC Document
Attachment 8_IRB Approval.pdf Research Determination	IC Document
Attachment 9_ Screening Survey Spanish.docx Screening Survey - Spanish	IC Document
Attachment 9_ Screening Survey Spanish.docx Screening Survey - Spanish	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

[NCIPC] Adolescent Mental Health Journey Mapping Project

Agency IC Tracking Number:

0920-1154-24HM

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction		Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Yes	Yes	Fillable Fileable
Other-Consent/Assent Forms		Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	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: 1,098

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 75 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	1,098	1,098
Annual IC Time Burden (Hours)	473	473
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA		07/19/2024
SSB		07/19/2024
PIA		07/19/2024
Research Determination		07/19/2024
Screening Survey - Spanish		07/19/2024

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

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