Information Collection

Experimental Survey

IC 202182 under ICR 201301-0910-004 · OMB 0910-0736.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
HPHC_Survey_Questions.pdf	Other-Survey
HPHC_Prototype1Cigarette22.pdf	Other-prototype
HPHC_Prototype1RollYourOwn10.pdf	Other-prototype
HPHC_Prototype2RollYourOwn02.pdf	Other-prototype
HPHC_Prototype3Cigarette22.pdf	Other-prototype
HPHC_Prototype3RollYourOwn02.pdf	Other-prototype
HPHC_Prototype4CigaretteNoGraphs05.pdf	Other-prototype
HPHC_Prototype4RollYourOwn10.pdf	Other-prototype
HPHC_Prototype5RollYourOwn02.pdf	Other-prototype
HPHC_Prototype6Cigarette2.pdf	Other-prototype
HPHC_Prototype6RollYourOwn02.pdf	Other-prototype

IC Title:

Experimental Survey

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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-Survey	HPHC_Survey_Questions.pdf	Yes	Yes	Fillable Fileable
Other-prototype	HPHC_Prototype1Cigarette22.pdf	Yes	Yes	Printable Only
Other-prototype	HPHC_Prototype1RollYourOwn10.pdf	Yes	Yes	Printable Only
Other-prototype	HPHC_Prototype2RollYourOwn02.pdf	Yes	Yes	Printable Only
Other-prototype	HPHC_Prototype3Cigarette22.pdf	Yes	Yes	Printable Only
Other-prototype	HPHC_Prototype3RollYourOwn02.pdf	Yes	Yes	Printable Only
Other-prototype	HPHC_Prototype4CigaretteNoGraphs05.pdf	Yes	Yes	Printable Only
Other-prototype	HPHC_Prototype4RollYourOwn10.pdf	Yes	Yes	Printable Only
Other-prototype	HPHC_Prototype5RollYourOwn02.pdf	Yes	Yes	Printable Only
Other-prototype	HPHC_Prototype6Cigarette2.pdf	Yes	Yes	Printable Only
Other-prototype	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
	Approved	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.