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Federal forms, ICRs, and supporting documents

Information Collection

Perceptions of Health Risk from Smokeless Tobacco Products and Nicotine Replacement Therapy among Pregnant Women and Women Planning a Pregnancy

IC 207620 under ICR 201109-0920-009 · OMB 0920-0910.

Documents and Forms
Document Name
Document Type
Other-Screener for Pregnant Women
Other-Screener for Non-pregnant wome
Other-Moderator's Guide for Pregnant
Other-Moderator's Guide for Non-Preg
Other-Consent Form
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Perceptions of Health Risk from Smokeless Tobacco Products and Nicotine Replacement Therapy among Pregnant Women and Women Planning a Pregnancy
 
New
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Screener for Pregnant Women Attachment 1a Screener pregnant_062513.docx Yes No Printable Only
Other-Screener for Non-pregnant women Attachment 1b Screener non-pregnant_062513.docx Yes No Printable Only
Other-Moderator's Guide for Pregnant Women Attachment 2a Moderator's Guide pregnant_062513.docx Yes No Printable Only
Other-Moderator's Guide for Non-Pregnant Women Attachment 2b Moderator's Guide non-pregnant_062513.docx Yes No Printable Only
Other-Consent Form Attachment 3. Consent_Form.doc Yes No Fillable Printable

Health Consumer Health and Safety

 

792 0
   
Individuals or Households
 
   0 %

  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 792 0 0 0 0 0
Annual IC Time Burden (Hours) 270 0 0 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Attachment 4 a Attachment 4 a. Approval Notice.13237.Amend.5-21-13.pdf 07/02/2013
Attachment 4b Attachment 4b. CDC exemption.pdf 07/02/2013
Attachment 5 Attachment 5. Confidentiality Agreement.doc 07/02/2013
attachment 6a attachment 6a. clearing-the-air_acc all participants.pdf 07/02/2013
attachment 6b attachment 6b. CTP_Quit_Postcard_current smokers.pdf 07/02/2013
0920-0910_Part A_Smoking Moms_062513 0920-0910_Part A_Smoking Moms_062513.docx 07/02/2013
0920-0910_Part B_Smoking Moms_062513 0920-0910_Part B_Smoking Moms_062513.docx 07/02/2013
attachment 7 attachment 7. Product information.docx 07/02/2013
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.