Information Collection

Sub-study #6_Resubmission of Health Information National Trends Survey 4 (HINTS 4) Cognitive Testing of HINTS-FDA Instrument

IC 208745 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⚠️ Notice: This information collection may be referencing outdated material.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 1 Sub-study #6_Resubmission of Health Information National Trends Survey 4 (HINTS 4) Cognitive Testing of HINTS-FDA Instrument	Form and Instruction
1 English Screener Attach E-1_Screener English-rev2.docx	Form and Instruction
2 Spanish Screener Attach E-2_Screener Spanish.docx	Form and Instruction
4 Spanish Cognitive Interview Script Attach B-2_Protocol Spanish.docx	Form and Instruction
3 English Cognitive Interview Script Attach B-1_Protocol English.docx	Form and Instruction
Justif Memo HINTS-FDA_9-4-2013.docx Justif Memo HINTS-FDA_9-4-2013	IC Document
Attach A-3_Tobacco Item Spreadsheet.xlsx Attach A-3_Tobacco Item Spreadsheet	IC Document
Attach A-1_Instrument-to-be-tested-English.doc Attach A-1_Instrument-to-be-tested-English	IC Document
Attach C-1_Consent Form English.docx Attach C-1_Consent Form English	IC Document
Attach C-2_Consent Form Spanish.docx Attach C-2_Consent Form Spanish	IC Document
Attach D_Advertisements.docx Attach D_Advertisements	IC Document
Attach F_Reminder Letter.docx Attach F_Reminder Letter	IC Document
Attach G_IRB Approval Letter.pdf Attach G_IRB Approval Letter	IC Document
Gen IC Form_HINTS-FDA.doc Gen IC Form_HINTS-FDA	IC Document
Attach A-2_Instrument-to-be-tested-Spanish.docx Attach A-2_Instrument-to-be-tested-Spanish	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Sub-study #6_Resubmission of Health Information National Trends Survey 4 (HINTS 4) Cognitive Testing of HINTS-FDA Instrument

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	1	English Screener	Attach E-1_Screener English-rev2.docx	No	No	Printable Only
Form and Instruction	2	Spanish Screener	Attach E-2_Screener Spanish.docx	No	No	Printable Only
Form and Instruction	4	Spanish Cognitive Interview Script	Attach B-2_Protocol Spanish.docx	No	No	Printable Only
Form and Instruction	3	English Cognitive Interview Script	Attach B-1_Protocol English.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: 95

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 New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	95	0	0	0	0	0
Annual IC Time Burden (Hours)	58	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Justif Memo HINTS-FDA_9-4-2013	Justif Memo HINTS-FDA_9-4-2013.docx	09/04/2013
Attach A-3_Tobacco Item Spreadsheet	Attach A-3_Tobacco Item Spreadsheet.xlsx	09/04/2013
Attach A-1_Instrument-to-be-tested-English	Attach A-1_Instrument-to-be-tested-English.doc	09/04/2013
Attach C-1_Consent Form English	Attach C-1_Consent Form English.docx	09/04/2013
Attach C-2_Consent Form Spanish	Attach C-2_Consent Form Spanish.docx	09/04/2013
Attach D_Advertisements	Attach D_Advertisements.docx	09/04/2013
Attach F_Reminder Letter	Attach F_Reminder Letter.docx	09/04/2013
Attach G_IRB Approval Letter	Attach G_IRB Approval Letter.pdf	09/04/2013
Gen IC Form_HINTS-FDA	Gen IC Form_HINTS-FDA.doc	09/04/2013
Attach A-2_Instrument-to-be-tested-Spanish	Attach A-2_Instrument-to-be-tested-Spanish.docx	09/05/2013

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