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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
[NCIPC] HEADS UO Outreach to At Risks Groups--Formative Testing
Agency IC Tracking Number:
0920-1154-23CC
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
0920-1154
Focus Group Recruitment Materials - Parents
Att 5_HU FG Recruitment Materials_Parents_English.docx
Yes
Yes
Fillable Fileable
Form and Instruction
0920-1154
Consent Form - Parent Participant
Att 2_HU Consent Form_Parent Participat_English.docx
Yes
Yes
Fillable Fileable
Instruction
Att 5_HU FG Recruitment Materials_Parents_English.docx
No
Printable Only
Form and Instruction
0920-1154
Focus Group Guide: Parents
Att 8_FG Guide Parents_English.docx
No
Paper Only
Form and Instruction
0920-1154
Focus Group Recruitment Materials - Youth
Att 4_HU FG Recruitment Materials_Youth.docx
Yes
Yes
Fillable Fileable
Form and Instruction
0920-1154
Consent Form - Parent of Youth Participant
Att 1_HU Consent Form_Parental Consent Form for Youth Participant.docx
Yes
Yes
Fillable Fileable
Instruction
Att 4_HU FG Recruitment Materials_Youth.docx
No
Paper Only
Form and Instruction
0920-1154
Focus Group Guide: Youth
Att 7_FG Guide Youth.docx
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Workforce Management
Subfunction:
Worker Safety
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
500
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
100 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
500
0
500
0
0
0
Annual IC Time Burden (Hours)
89
0
89
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
SSA
OMB- Supporting Statement A-FGs HU_Updated 11.29.22.docx
01/26/2023
SSB
OMB- Supporting Statement B- FGs HU_12.2.22.docx
01/26/2023
Att 6_HU FG Recruitment Materials_Parents_ES-US (Spanish)
Att 6_HU FG Recruitment Materials_Parents_ES-US.docx
01/26/2023
Att 9_FG Guide Parens_ES_US (Spanish)
Att 9_FG Guide Parents_ES-US.docx
01/26/2023
Att 10_10502-NHSR
Att. 10_10502-NHSR.pdf
01/26/2023
Privacy Act Determination
HEADS UP Outreach to At Risk Groups - GenIC-PII-Privacy Act-Determination-signed.pdf
01/26/2023
STARS Clearance
HEADS UP Outreach to At Risk Groups_STARS Clearance document.pdf
01/26/2023
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.