Information Collection

Sub-study #3 Self-Affirmation REVISED

IC 203967 under ICR 201111-0925-003 · OMB 0925-0645.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0645 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Sub-study #3 Self-Affirmation REVISED	Form and Instruction
1 Self-Affirm Survey #3B_Attach_Self- Affirm Survey_Screenshots.doc	Form and Instruction
#3_Justif Memo_Self-Affirm7_17_2012.doc #3_Justif Memo_Self-Affirm7_17_2012	IC Document
#3A_Attach_Self-Affirm Survey_Word format.doc #3A_Attach_Self-Affirm Survey_Word format	IC Document
#3C_Attach_Readings.doc #3C_Attach_Readings	IC Document
#3D_Attach IRB Approval.pdf #3D_Attach IRB Approval	IC Document

IC Title:

Sub-study #3 Self-Affirmation REVISED

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Self-Affirm Survey	#3B_Attach_Self- Affirm Survey_Screenshots.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 250

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	250	0	0	0	0	0
Annual IC Time Burden (Hours)	125	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
#3_Justif Memo_Self-Affirm7_17_2012	#3_Justif Memo_Self-Affirm7_17_2012.doc	08/31/2012
#3A_Attach_Self-Affirm Survey_Word format	#3A_Attach_Self-Affirm Survey_Word format.doc	08/31/2012
#3C_Attach_Readings	#3C_Attach_Readings.doc	08/31/2012
#3D_Attach IRB Approval	#3D_Attach IRB Approval.pdf	08/31/2012

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