Information Collection

Customer Feedback Information for National Institute on Drug Abuse PEERx Videos

IC 212391 under ICR 201202-0925-001 · OMB 0925-0655.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0655 can be found here:

2015-03-27 - Extension without change of a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Customer Feedback Information for National Institute on Drug Abuse PEERx Videos	Form and Instruction
1 Screenshot Student Survey Attachment 10- Screenshot Student Questionnaire.pdf	Form and Instruction
2 Screenshot Teacher Survey Attachment 11- Screenshot-Teacher Questionnaire.pdf	Form and Instruction
3 Messaging Moderator’s Guide Attachment 12 -_Messaging _Moderators Guide Prescription.doc	Form
4 FG Moderator’s Guide Attachment 13 -FG_ModeratorsGuide PEERx Video Testing.doc	Form
5 Student Focus Group Recruitment Screener Attachment 14- Student Focus Group Recruitment Screener.docx	Form
Attachment 1 - Sampling Plan -04032014.doc Sampling Plan	IC Document
Attachment 2 - Letter to Principals Explaining Study 04032014.pdf Letter to Principals Explaining Study	IC Document
Attachment 3 - Principal's Consent Form.doc Principal’s Consent Form	IC Document
Attachment 4 -Request to Principals to Host a Focus Group.docx Request to Principals to Host Focus Group	IC Document
Attachment 5 - Consent Assent Focus Group Participation -.docx Consent Assent Focus Group Participation	IC Document
Attachment 6 - Consent Assent Survey.docx Consent Assent Survey	IC Document
Attachment 7 -Teacher Consent -.docx Teacher Consent	IC Document
IRB Approval Letter - Customer Satisfaction NIDA PEERx Videos 04032014.pdf IRB Approval Letter	IC Document
Attachment 8 - Student Survey.doc Student Survey	IC Document
Attachment 9- Teacher Survey.doc Teacher Survey	IC Document
NIDA Fast Track Template 04032104 - Customer Feedback Information on NIDAs Choose Your Path Videos-20140313J (2).doc Fast Track Template	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Customer Feedback Information for National Institute on Drug Abuse PEERx Videos

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	1	Screenshot Student Survey	Attachment 10- Screenshot Student Questionnaire.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	2	Screenshot Teacher Survey	Attachment 11- Screenshot-Teacher Questionnaire.pdf	Yes	Yes	Fillable Fileable
Form	3	Messaging Moderatorâs Guide	Attachment 12 -_Messaging _Moderators Guide Prescription.doc	No		Paper Only
Form	4	FG Moderatorâs Guide	Attachment 13 -FG_ModeratorsGuide PEERx Video Testing.doc	No		Paper Only
Form	5	Student Focus Group Recruitment Screener	Attachment 14- Student Focus Group Recruitment Screener.docx	No		Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 798

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	798	798
Annual IC Time Burden (Hours)	391	391
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Sampling Plan	Attachment 1 - Sampling Plan -04032014.doc	07/24/2014
Letter to Principals Explaining Study	Attachment 2 - Letter to Principals Explaining Study 04032014.pdf	07/24/2014
Principalâs Consent Form	Attachment 3 - Principal's Consent Form.doc	07/27/2014
Request to Principals to Host Focus Group	Attachment 4 -Request to Principals to Host a Focus Group.docx	07/27/2014
Consent Assent Focus Group Participation	Attachment 5 - Consent Assent Focus Group Participation -.docx	07/27/2014
Consent Assent Survey	Attachment 6 - Consent Assent Survey.docx	07/27/2014
Teacher Consent	Attachment 7 -Teacher Consent -.docx	07/27/2014
IRB Approval Letter	IRB Approval Letter - Customer Satisfaction NIDA PEERx Videos 04032014.pdf	07/27/2014
Student Survey	Attachment 8 - Student Survey.doc	07/27/2014
Teacher Survey	Attachment 9- Teacher Survey.doc	07/27/2014
Fast Track Template	NIDA Fast Track Template 04032104 - Customer Feedback Information on NIDAs Choose Your Path Videos-20140313J (2).doc	07/27/2014

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