Screening and Consent

Evaluation of the National Tobacco Prevention and Control Public Education Campaign

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0923 can be found here:

Documents and Forms

Document Name Document Type
Screening and Consent Form
Screen and Consent Att E-1 Screening and Consent Process_1-6-12 (REVISED 2-7-12).docx Form
Att E-2 Email Notification and Reminders_1-6-12 (REVISED 2-7-12).doc Att E-2 Email Notification and Reminders_1-6-12 (REVISED 2-7-12) IC Document

Information Collection (IC) Details

IC Title:	Screening and Consent	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Screen and Consent	Att E-1 Screening and Consent Process_1-6-12 (REVISED 2-7-12).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 34,660	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	34,660	34,660
Annual IC Time Burden (Hours)	1,155	1,155
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att E-2 Email Notification and Reminders_1-6-12 (REVISED 2-7-12)	Att E-2 Email Notification and Reminders_1-6-12 (REVISED 2-7-12).doc	02/17/2012

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