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.

⚠️ Notice: This information collection may be referencing outdated material.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
Attachment 1a Screener pregnant_062513.docx	Other-Screener for Pregnant Women
Attachment 1b Screener non-pregnant_062513.docx	Other-Screener for Non-pregnant wome
Attachment 2a Moderator's Guide pregnant_062513.docx	Other-Moderator's Guide for Pregnant
Attachment 2b Moderator's Guide non-pregnant_062513.docx	Other-Moderator's Guide for Non-Preg
Attachment 3. Consent_Form.doc	Other-Consent Form
Attachment 4 a. Approval Notice.13237.Amend.5-21-13.pdf Attachment 4 a	IC Document
Attachment 4b. CDC exemption.pdf Attachment 4b	IC Document
Attachment 5. Confidentiality Agreement.doc Attachment 5	IC Document
attachment 6a. clearing-the-air_acc all participants.pdf attachment 6a	IC Document
attachment 6b. CTP_Quit_Postcard_current smokers.pdf attachment 6b	IC Document
0920-0910_Part A_Smoking Moms_062513.docx 0920-0910_Part A_Smoking Moms_062513	IC Document
0920-0910_Part B_Smoking Moms_062513.docx 0920-0910_Part B_Smoking Moms_062513	IC Document
attachment 7. Product information.docx attachment 7	IC Document

IC Title:

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

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	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

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 792

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	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

Documents for IC

table that charts IC Documents
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.