Information Collection

Sub-study #4_Alternative Tobacco Products Study

IC 207184 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⚠️ Notice: This information collection may be referencing outdated material.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:

2014-10-15 - Revision of a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 Sub-study #4_Alternative Tobacco Products Study	Form and Instruction
2 Baseline Survey B_Baseline Questionnaire 5-6-2013.doc	Form and Instruction
1 Screener G_Screeners 5-31-2013.docx	Form and Instruction
5 Moderators Guide and Interview E2_Moderator Guide Final ET 5-31-2013.docx	Form and Instruction
3 Eye Tracking Survey D_Eye Tracking Questionnaire_5-31-2013.doc	Form and Instruction
4 Moderator Guide & Focus Group E1_Moderator Guide Final ET+FG 5-31-2013.docx	Form and Instruction
2 and 3 Attachment B and D Screenshots B&D Screenshots Baseline & Eye Track Qx_5.31.13[1].pdf	Form and Instruction
A_Consent Forms 5.6.2013.docx A_Consent Forms 5	IC Document
C_Snus Advertisements 5-2-13.pdf C_Snus Advertisements 5-2-13	IC Document
F_Recruitment Materials 5-6-2013.docx F_Recruitment Materials 5-6-2013	IC Document
H_Debriefing 5-2-2013.doc H_Debriefing 5-2-2013	IC Document
I_OHSRP Exemption.pdf I_OHSRP Exemption	IC Document
Justif Memo Snus 5-31-2013.doc Justif Memo Snus 5-31-2013	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Sub-study #4_Alternative Tobacco Products Study

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 and Instruction	2	Baseline Survey	B_Baseline Questionnaire 5-6-2013.doc	Yes	Yes	Fillable Fileable
Form and Instruction	1	Screener	G_Screeners 5-31-2013.docx	No	No	Printable Only
Form and Instruction	5	Moderators Guide and Interview	E2_Moderator Guide Final ET 5-31-2013.docx	No	No	Printable Only
Form and Instruction	3	Eye Tracking Survey	D_Eye Tracking Questionnaire_5-31-2013.doc	Yes	Yes	Fillable Fileable
Form and Instruction	4	Moderator Guide & Focus Group	E1_Moderator Guide Final ET+FG 5-31-2013.docx	No	No	Printable Only
Form and Instruction	2 and 3	Attachment B and D Screenshots	B&D Screenshots Baseline & Eye Track Qx_5.31.13[1].pdf	Yes	Yes	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: SORN #09-25-0156, "Records of Participants in Programs and Respondents in Surveys Used to Evaluate Programs of the Public Health Service, HHS/PHS/NIH/OD"

FR Citation: 67 FR 60743

Number of Respondents: 192

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 30 %

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	192	0	0	0	0	0
Annual IC Time Burden (Hours)	72	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
A_Consent Forms 5	A_Consent Forms 5.6.2013.docx	05/07/2013
C_Snus Advertisements 5-2-13	C_Snus Advertisements 5-2-13.pdf	05/07/2013
F_Recruitment Materials 5-6-2013	F_Recruitment Materials 5-6-2013.docx	05/07/2013
H_Debriefing 5-2-2013	H_Debriefing 5-2-2013.doc	05/07/2013
I_OHSRP Exemption	I_OHSRP Exemption.pdf	05/07/2013
Justif Memo Snus 5-31-2013	Justif Memo Snus 5-31-2013.doc	05/31/2013

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