Information Collection

Sub-study #4: Cognitive Testing of the Family Life, Activity, Sun, Health, and Eating (FLASHE) Survey

IC 202800 under ICR 201302-0925-007 · OMB 0925-0589.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0589 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 Sub-study #4: Cognitive Testing of the Family Life, Activity, Sun, Health, and Eating (FLASHE) Survey	Form and Instruction
2 Parent Diet and Demographic Survey Attach 4A-1 FLASHE Parent Diet And Demographics Survey.doc	Form and Instruction
3 Parent Physical Activity Survey and Checklist Attach 4A-2 FLASHE Parent PA Survey and Activity Checklist.pdf	Form and Instruction
4 Teen Diet and Demographic Survey Attach 4A-3 FLASHE Teenager Diet and Demographics Survey.doc	Form and Instruction
1 FLASHE Screener Attach 4F Screener.docx	Form and Instruction
5 Teen Physical Activity Survey and Recall Attach 4A-4 FLASHE Teenager PA Survey and Activity Recall.pdf	Form and Instruction
6 Parent Cognitive Interview Guide Attach 4B-1 and 4B-2 Parent Cognitive Interview Guide.docx	Form and Instruction
7 Teen Cognitive Interview Guide Attach 4B-3 and 4B-4 Teenager Cognitive Interview Guide.docx	Form and Instruction
Attach 4C Informed Consent Forms - Parent and Teen.docx Attach 4C Informed Consent Forms - Parent and Teen	IC Document
Generic Sub-Study Form.doc Generic Sub-Study Form	IC Document
Justification Memo.doc Justification Memo	IC Document
Attach 4D Reminder Letter-Email.docx Attach 4D Reminder Letter-Email	IC Document
Attach 4E FLASHE Cognitive Testing Plan.docx Attach 4E FLASHE Cognitive Testing Plan	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Sub-study #4: Cognitive Testing of the Family Life, Activity, Sun, Health, and Eating (FLASHE) Survey

Agency IC Tracking Number:

IC Status: Modified

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	2	Parent Diet and Demographic Survey	Attach 4A-1 FLASHE Parent Diet And Demographics Survey.doc	No	No	Printable Only
Form and Instruction	3	Parent Physical Activity Survey and Checklist	Attach 4A-2 FLASHE Parent PA Survey and Activity Checklist.pdf	No	No	Printable Only
Form and Instruction	4	Teen Diet and Demographic Survey	Attach 4A-3 FLASHE Teenager Diet and Demographics Survey.doc	No	No	Printable Only
Form and Instruction	1	FLASHE Screener	Attach 4F Screener.docx	No	No	Printable Only
Form and Instruction	5	Teen Physical Activity Survey and Recall	Attach 4A-4 FLASHE Teenager PA Survey and Activity Recall.pdf	No	No	Printable Only
Form and Instruction	6	Parent Cognitive Interview Guide	Attach 4B-1 and 4B-2 Parent Cognitive Interview Guide.docx	No	No	Printable Only
Form and Instruction	7	Teen Cognitive Interview Guide	Attach 4B-3 and 4B-4 Teenager Cognitive Interview Guide.docx	No	No	Printable Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: SORN #09-25-0156, "Records of Participants in Programs and Respondents in Surveys Used to Evaluate Programs of the Public Health Service, HHS/PHS/NIH/OD"

FR Citation: 67 FR 60743

Number of Respondents: 80

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	80	80
Annual IC Time Burden (Hours)	63	63
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attach 4C Informed Consent Forms - Parent and Teen	Attach 4C Informed Consent Forms - Parent and Teen.docx	02/27/2013
Generic Sub-Study Form	Generic Sub-Study Form.doc	02/27/2013
Justification Memo	Justification Memo.doc	02/27/2013
Attach 4D Reminder Letter-Email	Attach 4D Reminder Letter-Email.docx	02/27/2013
Attach 4E FLASHE Cognitive Testing Plan	Attach 4E FLASHE Cognitive Testing Plan.docx	02/27/2013

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