Information Collection

Sub-study #4: Cognitive Testing of the Family Life, Activity, Sun, Health, and Eating (FLASHE) Survey

IC 202800 under ICR 201103-0925-004 · OMB 0925-0589.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0589 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Sub-study #4: Cognitive Testing of the Family Life, Activity, Sun, Health, and Eating (FLASHE) Survey	Form and Instruction
1 FLASHE Screener Attach 4F Screener.docx	Form and Instruction
2 Parent Diet and Demographic Survey Attach 4A-1 FLASHE Parent Diet And Demographics Survey.doc	Form and Instruction
3 Parent Physical Activity Survey and Checklist Attach 4A-2 FLASHE Parent PA Survey and Activity Checklist.pdf	Form and Instruction
4 Teen Diet and Demographic Survey Attach 4A-3 FLASHE Teenager Diet and Demographics Survey.doc	Form and Instruction
5 Teen Physical Activity Survey and Recall Attach 4A-4 FLASHE Teenager PA Survey and Activity Recall.pdf	Form and Instruction
6 Parent Cognitive Interview Guide Attach 4B-1 and 4B-2 Parent Cognitive Interview Guide.docx	Form and Instruction
7 Teen Cognitive Interview Guide Attach 4B-3 and 4B-4 Teenager Cognitive Interview Guide.docx	Form and Instruction
Generic Sub-Study Form.doc Gen IC Summary	IC Document
Justification Memo.doc Justification Memo	IC Document
Attach 4C Informed Consent Forms - Parent and Teen.docx Attach 4C Informed Consent Forms - Parent and Teen	IC Document
Attach 4D Reminder Letter-Email.docx Attach 4D Reminder Letter-Email	IC Document
Attach 4E FLASHE Cognitive Testing Plan.docx Attach 4E FLASHE Cognitive Testing Plan	IC Document

IC Title:

Sub-study #4: Cognitive Testing of the Family Life, Activity, Sun, Health, and Eating (FLASHE) Survey

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	FLASHE Screener	Attach 4F Screener.docx	No	No	Printable Only
Form and Instruction	2	Parent Diet and Demographic Survey	Attach 4A-1 FLASHE Parent Diet And Demographics Survey.doc	No	No	Printable Only
Form and Instruction	3	Parent Physical Activity Survey and Checklist	Attach 4A-2 FLASHE Parent PA Survey and Activity Checklist.pdf	No	No	Printable Only
Form and Instruction	4	Teen Diet and Demographic Survey	Attach 4A-3 FLASHE Teenager Diet and Demographics Survey.doc	No	No	Printable Only
Form and Instruction	5	Teen Physical Activity Survey and Recall	Attach 4A-4 FLASHE Teenager PA Survey and Activity Recall.pdf	No	No	Printable Only
Form and Instruction	6	Parent Cognitive Interview Guide	Attach 4B-1 and 4B-2 Parent Cognitive Interview Guide.docx	No	No	Printable Only
Form and Instruction	7	Teen Cognitive Interview Guide	Attach 4B-3 and 4B-4 Teenager Cognitive Interview Guide.docx	No	No	Printable Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: Records of Participants in Programs and Respondents in Surveys Used to Evaluate Programs of the Public Health Service, HHS/PHS/NIH/OD

FR Citation: 67 FR 60743

Number of Respondents: 80

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	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	80	0	0	0	0	0
Annual IC Time Burden (Hours)	63	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Gen IC Summary	Generic Sub-Study Form.doc	05/22/2012
Justification Memo	Justification Memo.doc	05/22/2012
Attach 4C Informed Consent Forms - Parent and Teen	Attach 4C Informed Consent Forms - Parent and Teen.docx	05/22/2012
Attach 4D Reminder Letter-Email	Attach 4D Reminder Letter-Email.docx	05/22/2012
Attach 4E FLASHE Cognitive Testing Plan	Attach 4E FLASHE Cognitive Testing Plan.docx	05/22/2012

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