Information Collection

Teen Form

IC 275093 under ICR 202504-0920-027 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Teen Form	Form and Instruction
Teen Teen Form	Form and Instruction
Teen Att 5_Teen Forms.docx	Form and Instruction
Teen Att 5_Teen forms.pdf	Form and Instruction
Att 10_Teen Forms in REDCap.pdf Teen Redcap copy	IC Document
Att 10_Teen Forms in REDCap.pdf Teen Redcap copy	IC Document

IC Title:

Teen Form

Agency IC Tracking Number:

0920-24EG

Is this a Common Form? No

IC Status: New

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	n/a				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0136, Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62811

Number of Respondents: 140

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	140	140
Annual IC Time Burden (Hours)	105	105
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Teen Redcap copy		09/22/2025

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

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