Baseline Care Survey for Pregnant Adolescent

Adolescent Family Life Care Program Core Evaluation

Documents and Forms

Document Name Document Type
Form 0990-0290 Baseline Care Survey for Pregnant Adolescent Form
0990-0290 Preganacy Teen 0990-0290Appendix B_Draft Care Pregnant Baseline for grantees_OMB_09-02-08_MK-JG-KLL.doc Form

Information Collection (IC) Details

IC Title:	Baseline Care Survey for Pregnant Adolescent	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	0990-0290	Preganacy Teen	0990-0290Appendix B_Draft Care Pregnant Baseline for grantees_OMB_09-02-08_MK-JG-KLL.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	10,000	-2,600	12,600
Annual IC Time Burden (Hours)	3,833	-2,467	6,300
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.