Parent Application Form

Attachment B OMB No. 0920-1185

Expiration Date: 03/31/2026

National Center for Health Statistics

Data Detectives Summer Camp

From the Office of Management and Budget (OMB No. 0920-1185, Expiration Date: 03/31/2026):

NOTICE - Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: CDC/ATSDR Information Collection Review Office; 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-1185).

Assurance of Confidentiality - We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C. 242m(d)) and the Confidential Information Protection and Statistical Efficiency Act of 2018 (CIPSEA Pub. L. No. 115-435, 132 Stat. 5529 § 302). In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you. In addition to the above cited laws, NCHS complies with the Federal Cybersecurity Enhancement Act of 2015 (6 U.S.C. §§ 151 and 151 note) which protects Federal information systems from cybersecurity risks by screening their networks.

Parent Application Form

______________________ ________________________ _________________________

Applicant’s last name Applicant’s first name Applicant’s middle initial

Parent or Guardian Information

This section is to be completed by the parent or guardian of camp applicant.

______________________ ________________________ _________________________

Last name First name Middle initial

Primary phone number: _________________________________________________

Alternate phone number: _________________________________________________

Email address*: __________________________________________________

*Please provide an e-mail address that you check frequently. We will be sending updates and announcements regarding your application.

How did you find out about this camp?

___ School counselor ___ Science or Math Teacher ___ Internet ___ Summer fair

___ Other, please specify________________________________________________

What is your child’s current statistical or math knowledge and interest?

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What would you like your child to gain from this camp? What are your expectations of this camp? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please check off the line below if you agree with the following statement:

____I acknowledge that I am the parent/guardian and I confirm that the information included is accurate to the best of my knowledge.

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