Adult Follow-up - Screenshot

Web-based Media Literacy Parent Training for Substance Use Prevention in Rural Locations

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0685 can be found here:

Documents and Forms

Document Name Document Type
Form 5 Adult Follow-up - Screenshot Form
5 Adult Follow-up Attachment 22 - Screenshot Adult Followup - MDF.zip Form
Attachment_5_-_Data_collection_instrument_-_Adult_questionnaire_Followup_MDF[1].pdf Adult Follow-up IC Document

Information Collection (IC) Details

IC Title:	Adult Follow-up - Screenshot	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	5	Adult Follow-up	Attachment 22 - Screenshot Adult Followup - MDF.zip		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: SORN 09-25-0200	FR Citation: 67 FR 60741

Number of Respondents: 200	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
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	150	150
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Adult Follow-up	Attachment_5_-_Data_collection_instrument_-_Adult_questionnaire_Followup_MDF[1].pdf	11/06/2013

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