Information Collection

National Tobacco Education Campaign: Rough Cut Testing of TV, Print, and Radio Ads

IC 204969 under ICR 201109-0920-009 · OMB 0920-0910.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0910 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
National Tobacco Education Campaign: Rough Cut Testing of TV, Print, and Radio Ads	Form
Screener for General Pop. and AI/AN Att 1(e) Screener-GenPop_AI-AN_2012_11_28.doc	Form
Screener for Spanish Speaking Hispanics Att 2(e) Screener_Spanish Speaking Hispanics (in English)_2012_11_28.doc	Form
Screener for Spanish Speaking Hispanics - Spanish Att 2(s) Screener_Spanish Speaking Hispanics (in Spanish)_2012_11_28.doc	Form
Main Questionnaire - English Att 3(e) Main Questionnaire (in English)_2012_11_28.doc	Form
Main Questionnaire - Spanish Att 3(s) Main Questionnaire (in Spanish)_2012_11_28.doc	Form
Att 4(e) Emails To Participants (in English).docx Att 4(e) - Email to Participants - English	IC Document
Att 4(s) Emails To Participants (in Spanish).docx Att 4(s) - Email to Participants - Spanish	IC Document
Att 5 (e) Privacy Policies.docx Att 5(e) - Privacy Policy -English	IC Document
Att 5 (s) Privacy Policies.docx Att 5(s) - Privacy Policy - Spanish	IC Document
Att 6 (e) Terms Of Use-Terms Conditions.docx Att 6(e) - Terms of Use - English	IC Document
Att 6 (s) Terms Of Use-Terms Conditions.docx Att 6(s) - Terms of Use - Spanish	IC Document
0920-0910_IC_4_Part A_2012_11_28.docx Supporting Statement A	IC Document
0920-0910_IC_4_Part B_2012 11 28.docx Supporting Statement B	IC Document

IC Title:

National Tobacco Education Campaign: Rough Cut Testing of TV, Print, and Radio Ads

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	none	Screener for General Pop. and AI/AN	Att 1(e) Screener-GenPop_AI-AN_2012_11_28.doc	Yes	Yes	Fillable Fileable
Form	none	Screener for Spanish Speaking Hispanics	Att 2(e) Screener_Spanish Speaking Hispanics (in English)_2012_11_28.doc	Yes	Yes	Fillable Fileable
Form	none	Screener for Spanish Speaking Hispanics - Spanish	Att 2(s) Screener_Spanish Speaking Hispanics (in Spanish)_2012_11_28.doc	Yes	Yes	Fillable Fileable
Form	none	Main Questionnaire - English	Att 3(e) Main Questionnaire (in English)_2012_11_28.doc	Yes	Yes	Fillable Fileable
Form	none	Main Questionnaire - Spanish	Att 3(s) Main Questionnaire (in Spanish)_2012_11_28.doc	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 21,900

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

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	21,900	0	0	0	0	0
Annual IC Time Burden (Hours)	2,050	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
Att 4(e) - Email to Participants - English	Att 4(e) Emails To Participants (in English).docx	11/29/2012
Att 4(s) - Email to Participants - Spanish	Att 4(s) Emails To Participants (in Spanish).docx	11/29/2012
Att 5(e) - Privacy Policy -English	Att 5 (e) Privacy Policies.docx	11/29/2012
Att 5(s) - Privacy Policy - Spanish	Att 5 (s) Privacy Policies.docx	11/29/2012
Att 6(e) - Terms of Use - English	Att 6 (e) Terms Of Use-Terms Conditions.docx	11/29/2012
Att 6(s) - Terms of Use - Spanish	Att 6 (s) Terms Of Use-Terms Conditions.docx	11/29/2012
Supporting Statement A	0920-0910_IC_4_Part A_2012_11_28.docx	11/29/2012
Supporting Statement B	0920-0910_IC_4_Part B_2012 11 28.docx	11/29/2012

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