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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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:

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.