Information Collection

Experimental Survey

IC 202182 under ICR 201205-0910-004 · OMB 0910-0736.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0910-0736 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix B-Stimuli.pdf	Other-Appendix B - Stimuli
HPHC_Prototype1Cigarette22.pdf	Other-HPHC Prototype 1 Cigarette 22
HPHC_Prototype1RollYourOwn10.pdf	Other-HPHC Prototype 1 Roll Your Own
HPHC_Prototype2Cigarette22.pdf	Other-HPHC Prototype 2 Cigarette 22
HPHC_Prototype2RollYourOwn02.pdf	Other-HPHC Prototype 2 Roll Your Own
HPHC_Prototype3Cigarette22.pdf	Other-HPHC Prototype 3 Cigarette 22
HPHC_Prototype3RollYourOwn02.pdf	Other-HPHC Prototype 3 Rool Your Own
HPHC_Prototype4CigaretteNoGraphs05.pdf	Other-HPHC Prototype 4 Cigarette No
HPHC_Prototype4RollYourOwn10.pdf	Other-HPHC Prototype 4 Roll Your Own
HPHC_Prototype5Cigarette3.pdf	Other-HPHC Prototype 5 Cigarette 3
HPHC_Prototype5RollYourOwn02.pdf	Other-HPHC Prototype 5 Roll Your Own
HPHC_Prototype6Cigarette2.pdf	Other-HPHC Prototype 6 Cigarette 2
HPHC_Prototype6RollYourOwn02.pdf	Other-HPHC Prototype 6 Roll Your Own

IC Title:

Experimental Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Appendix B - Stimuli	Appendix B-Stimuli.pdf	Yes	Yes	Printable Only
Other-HPHC Prototype 1 Cigarette 22	HPHC_Prototype1Cigarette22.pdf	Yes	Yes	Printable Only
Other-HPHC Prototype 1 Roll Your Own 10	HPHC_Prototype1RollYourOwn10.pdf	Yes	Yes	Printable Only
Other-HPHC Prototype 2 Cigarette 22	HPHC_Prototype2Cigarette22.pdf	Yes	Yes	Printable Only
Other-HPHC Prototype 2 Roll Your Own 02	HPHC_Prototype2RollYourOwn02.pdf	Yes	Yes	Printable Only
Other-HPHC Prototype 3 Cigarette 22	HPHC_Prototype3Cigarette22.pdf	Yes	Yes	Printable Only
Other-HPHC Prototype 3 Rool Your Own 02	HPHC_Prototype3RollYourOwn02.pdf	Yes	Yes	Printable Only
Other-HPHC Prototype 4 Cigarette No Graphs 05	HPHC_Prototype4CigaretteNoGraphs05.pdf	Yes	Yes	Printable Only
Other-HPHC Prototype 4 Roll Your Own 10	HPHC_Prototype4RollYourOwn10.pdf	Yes	Yes	Printable Only
Other-HPHC Prototype 5 Cigarette 3	HPHC_Prototype5Cigarette3.pdf	Yes	Yes	Printable Only
Other-HPHC Prototype 5 Roll Your Own 2	HPHC_Prototype5RollYourOwn02.pdf	Yes	Yes	Printable Only
Other-HPHC Prototype 6 Cigarette 2	HPHC_Prototype6Cigarette2.pdf	Yes	Yes	Printable Only
Other-HPHC Prototype 6 Roll Your Own 02	HPHC_Prototype6RollYourOwn02.pdf	Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,150

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,150	3,150
Annual IC Time Burden (Hours)	1,575	1,575
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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