Adolescent Telephone Screening Script

Evaluation of the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) Quality Demonstration Grant Program

Documents and Forms

Document Name Document Type
Form 14 Adolescent Telephone Screening Script Form and Instruction
14 Adolescent Telephone Screening Script Attachment R- 2014 Adolescent Telephone Screening Script.docx Form and Instruction
Attachment Q- 2014 Adolescent Focus Group Recruitment Materials.docx Attachment Q- 2014 Adolescent Focus Group Recruitment Materials IC Document

Information Collection (IC) Details

IC Title:	Adolescent Telephone Screening Script	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 and Instruction	14	Adolescent Telephone Screening Script	Attachment R- 2014 Adolescent Telephone Screening Script.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 57	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	57	57
Annual IC Time Burden (Hours)	5	5
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment Q- 2014 Adolescent Focus Group Recruitment Materials	Attachment Q- 2014 Adolescent Focus Group Recruitment Materials.docx	02/19/2014

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