Viewers Feedback Form

Assessment of the Underage Drinking Prevention Education Initiatives State/Territory Videos Project

Documents and Forms

Document Name Document Type
Form Attachment 3 Viewers Feedback Form Form and Instruction
Attachment 3 Video Viewers Feedback Form Attachment 3_Video Viewers Feedback Form.doc Form and Instruction
Attachment 4_Report on UAD Prevention Videos A Four-State Pilot Project.pdf Report on UAD Prevention Video IC Document
Attachment 5_ICF Macro IRB Review Findings Form_State-Territory Videos Project.pdf IRB IC Document
Attachment 6_State-Territory Videos Project_Communications Sent Prior to Assessment.pdf Communications Sent Prior to Assessment IC Document

Information Collection (IC) Details

IC Title:	Viewers Feedback Form	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	Attachment 3	Video Viewers Feedback Form	Attachment 3_Video Viewers Feedback Form.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,056	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,056	3,056
Annual IC Time Burden (Hours)	254	254
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Report on UAD Prevention Video	Attachment 4_Report on UAD Prevention Videos A Four-State Pilot Project.pdf	08/09/2011
IRB	Attachment 5_ICF Macro IRB Review Findings Form_State-Territory Videos Project.pdf	08/09/2011
Communications Sent Prior to Assessment	Attachment 6_State-Territory Videos Project_Communications Sent Prior to Assessment.pdf	08/09/2011

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