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⚠️ Notice: This information collection may be referencing outdated material.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

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:

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 %

	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

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.