Information Collection

Cognitive Testing for the PATH Study Wave 4 Questionnaires

IC 217825 under ICR 201209-0925-001 · OMB 0925-0663.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0663 can be found here:

2015-10-20 - Revision of a currently approved collection

Documents and Forms

Document Name Document Type
Form A-1 Cognitive Testing for the PATH Study Wave 4 Questionnaires Form and Instruction
A-1 Recruitment Screener PATH Cognitive Testing Sub-study Attachment A-1. Adult Recruitment Screener 061915.docx Form and Instruction
A-2 Recruitment Screener PATH Cognitive Testing Sub-study Attachment A-2. ENDs Recruitment Screener 062215.docx Form and Instruction
A-3 Recruitment Screener PATH Cognitive Testing Sub-study Attachment A-3. Youth Recruitment Screener 061815.docx Form and Instruction
A-4 Recruitment Screener PATH Cognitive Testing Sub-study Attachment A-4. Young Adult Recruitment Screener 061915.docx Form and Instruction
B-1 Adult Interview Intro. PATH Cognitive Testing Sub-study Attachment B-1. Adult Interview Introduction 062115.docx Form and Instruction
B-2 ENDS Interview Into. PATH Cognitive Testing Sub-study Attachment B-2. ENDS Interview Introduction 062115.docx Form and Instruction
B-3 Youth Interview Intro PATH Cognitive Testing Sub-study Attachment B-3. Youth Interview Introduction 062115.docx Form and Instruction
B-4 Screening Module PATH Cognitive Testing Sub-study Attachment B-4. Screening Module 062115.docx Form and Instruction
B-5 Screening Module Images PATH Cognitive Testing Sub-study Attachment B-5. Screening Module Images 062115.docx Form and Instruction
B-6 Adult Cigarettes Modlue PATH Cognitive Testing Sub-study Attachment B-6. Adult Cigarettes Module 062115.docx Form and Instruction
B-7 Adult Hookah Module PATH Cognitive Testing Sub-study Attachment B-7. Adult Hookah Module 062215.docx Form and Instruction
B-8 Adult Smokeless/Snus Module PATH Cognitive Testing Sub-study Attachment B-8. Adult Smokeless Snus Module 062115.docx Form and Instruction
B-9 Adult Harm Perceptions Module PATH Cognitive Testing Sub-study Attachment B-9. Adult Harm Perceptions Module 062115.docx Form and Instruction
B-10 Adult Media Module PATH Cognitive Testing Sub-study Attachment B-10. Adult Media Module 062115.docx Form and Instruction
B-11 Social Media Card Sort Imagines PATH Cognitive Testing Sub-study Attachment B-11. Social Media Card Sort Images 062115.docx Form and Instruction
B-12 Adult Barcode Module PATH Cognitive Testing Sub-study Attachment B-12. Adult Barcode Scanning Module 062115.docx Form and Instruction
B-13 Adult ENDS Module PATH Cognitive Testing Sub-study Attachment B-13. Adult ENDs Module 062115.docx Form and Instruction
B-14 Young Adult Cigarettes Module PATH Cognitive Testing Sub-study Attachment B-14. Young Adult Cigarettes Module 062115.docx Form and Instruction
B-15 Young Adult Hookah Module PATH Cognitive Testing Sub-study Attachment B-15. Young Adult Hookah Module 062215.docx Form and Instruction
B-16 Young Adult Demographics Module PATH Cognitive Testing Sub-study Attachment B-16. Young Adult Demographics Module 062115.docx Form and Instruction
B-17 Youth Cigarettes Modulle PATH Cognitive Testing Sub-study Attachment B-17. Youth Cigarettes Module 062115.docx Form and Instruction
B-18 Youth Hookah Module PATH Cognitive Testing Sub-study Attachment B-18. Youth Hookah Module 062115.docx Form and Instruction
B-19 Youth Social Norms Module PATH Cognitive Testing Sub-study Attachment B-19. Youth Social Norms Module 062115.docx Form and Instruction
B-20 Youth Harm Perceptions Module PATH Cognitive Testing Sub-study Attachment B-20. Youth Harm Perceptions Module 062115.docx Form and Instruction
B-21 Youth Media Module PATH Cognitive Testing Sub-study Attachment B-21. Youth Media Module 062115.docx Form and Instruction
PATH Study Cognitive Testing Sub-study Memo 0925-0663 final rev 8-10-15.docx Gen IC Justification Memo IC Document
PATH Cognitive Testing Sub-study Attachment C. IRB Approval Letter.pdf IRB Approval Letter IC Document
PATH Cognitive Testing Sub-study Attachment D-1. Adult Consent Form 060415.docx Consent Form IC Document
PATH Cognitive Testing Sub-study Attachment D-2 Parental Permission and Youth Assent Form 071715.docx Parental Permission and Youth Assent Forms IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Cognitive Testing for the PATH Study Wave 4 Questionnaires	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	A-1	Recruitment Screener	PATH Cognitive Testing Sub-study Attachment A-1. Adult Recruitment Screener 061915.docx	Yes	Yes	Fillable Fileable
Form and Instruction	A-2	Recruitment Screener	PATH Cognitive Testing Sub-study Attachment A-2. ENDs Recruitment Screener 062215.docx	Yes	Yes	Fillable Fileable
Form and Instruction	A-3	Recruitment Screener	PATH Cognitive Testing Sub-study Attachment A-3. Youth Recruitment Screener 061815.docx	Yes	Yes	Fillable Fileable
Form and Instruction	A-4	Recruitment Screener	PATH Cognitive Testing Sub-study Attachment A-4. Young Adult Recruitment Screener 061915.docx	Yes	Yes	Fillable Fileable
Form and Instruction	B-1	Adult Interview Intro.	PATH Cognitive Testing Sub-study Attachment B-1. Adult Interview Introduction 062115.docx	Yes	Yes	Fillable Fileable
Form and Instruction	B-2	ENDS Interview Into.	PATH Cognitive Testing Sub-study Attachment B-2. ENDS Interview Introduction 062115.docx	Yes	Yes	Fillable Fileable
Form and Instruction	B-3	Youth Interview Intro	PATH Cognitive Testing Sub-study Attachment B-3. Youth Interview Introduction 062115.docx	Yes	Yes	Fillable Fileable
Form and Instruction	B-4	Screening Module	PATH Cognitive Testing Sub-study Attachment B-4. Screening Module 062115.docx	Yes	Yes	Fillable Fileable
Form and Instruction	B-5	Screening Module Images	PATH Cognitive Testing Sub-study Attachment B-5. Screening Module Images 062115.docx	Yes	Yes	Fillable Fileable
Form and Instruction	B-6	Adult Cigarettes Modlue	PATH Cognitive Testing Sub-study Attachment B-6. Adult Cigarettes Module 062115.docx	Yes	Yes	Fillable Fileable
Form and Instruction	B-7	Adult Hookah Module	PATH Cognitive Testing Sub-study Attachment B-7. Adult Hookah Module 062215.docx	Yes	Yes	Fillable Fileable
Form and Instruction	B-8	Adult Smokeless/Snus Module	PATH Cognitive Testing Sub-study Attachment B-8. Adult Smokeless Snus Module 062115.docx	Yes	Yes	Fillable Fileable
Form and Instruction	B-9	Adult Harm Perceptions Module	PATH Cognitive Testing Sub-study Attachment B-9. Adult Harm Perceptions Module 062115.docx	Yes	Yes	Fillable Fileable
Form and Instruction	B-10	Adult Media Module	PATH Cognitive Testing Sub-study Attachment B-10. Adult Media Module 062115.docx	Yes	Yes	Fillable Fileable
Form and Instruction	B-11	Social Media Card Sort Imagines	PATH Cognitive Testing Sub-study Attachment B-11. Social Media Card Sort Images 062115.docx	Yes	Yes	Fillable Fileable
Form and Instruction	B-12	Adult Barcode Module	PATH Cognitive Testing Sub-study Attachment B-12. Adult Barcode Scanning Module 062115.docx	Yes	Yes	Fillable Fileable
Form and Instruction	B-13	Adult ENDS Module	PATH Cognitive Testing Sub-study Attachment B-13. Adult ENDs Module 062115.docx	Yes	Yes	Fillable Fileable
Form and Instruction	B-14	Young Adult Cigarettes Module	PATH Cognitive Testing Sub-study Attachment B-14. Young Adult Cigarettes Module 062115.docx	Yes	Yes	Fillable Fileable
Form and Instruction	B-15	Young Adult Hookah Module	PATH Cognitive Testing Sub-study Attachment B-15. Young Adult Hookah Module 062215.docx	Yes	Yes	Fillable Fileable
Form and Instruction	B-16	Young Adult Demographics Module	PATH Cognitive Testing Sub-study Attachment B-16. Young Adult Demographics Module 062115.docx	Yes	Yes	Fillable Fileable
Form and Instruction	B-17	Youth Cigarettes Modulle	PATH Cognitive Testing Sub-study Attachment B-17. Youth Cigarettes Module 062115.docx	Yes	Yes	Fillable Fileable
Form and Instruction	B-18	Youth Hookah Module	PATH Cognitive Testing Sub-study Attachment B-18. Youth Hookah Module 062115.docx	Yes	Yes	Fillable Fileable
Form and Instruction	B-19	Youth Social Norms Module	PATH Cognitive Testing Sub-study Attachment B-19. Youth Social Norms Module 062115.docx	Yes	Yes	Fillable Fileable
Form and Instruction	B-20	Youth Harm Perceptions Module	PATH Cognitive Testing Sub-study Attachment B-20. Youth Harm Perceptions Module 062115.docx	Yes	Yes	Fillable Fileable
Form and Instruction	B-21	Youth Media Module	PATH Cognitive Testing Sub-study Attachment B-21. Youth Media Module 062115.docx	Yes	Yes	Fillable Fileable

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: 1,071	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,071	1,071
Annual IC Time Burden (Hours)	213	213
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Gen IC Justification Memo	PATH Study Cognitive Testing Sub-study Memo 0925-0663 final rev 8-10-15.docx	08/10/2015
IRB Approval Letter	PATH Cognitive Testing Sub-study Attachment C. IRB Approval Letter.pdf	08/10/2015
Consent Form	PATH Cognitive Testing Sub-study Attachment D-1. Adult Consent Form 060415.docx	08/10/2015
Parental Permission and Youth Assent Forms	PATH Cognitive Testing Sub-study Attachment D-2 Parental Permission and Youth Assent Form 071715.docx	08/10/2015

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