Information Collection

National Tobacco Education Campaign: Rough Cut Testing of TV, Print, and Radio Ads

IC 204969 under ICR 201306-0920-004 · OMB 0920-0910.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0910 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
National Tobacco Education Campaign: Rough Cut Testing of TV, Print, and Radio Ads	Form
Screener for General Pop. and AI/AN Att 1(e) Screener-GenPop_AI-AN_2012_11_28.doc	Form
Screener for Spanish Speaking Hispanics Att 2(e) Screener_Spanish Speaking Hispanics (in English)_2012_11_28.doc	Form
Screener for Spanish Speaking Hispanics - Spanish Att 2(s) Screener_Spanish Speaking Hispanics (in Spanish)_2012_11_28.doc	Form
Main Questionnaire - English Att 3(e) Main Questionnaire (in English)_2012_11_28.doc	Form
Main Questionnaire - Spanish Att 3(s) Main Questionnaire (in Spanish)_2012_11_28.doc	Form
Att 4(e) Emails To Participants (in English).docx Att 4(e) - Email to Participants - English	IC Document
Att 4(s) Emails To Participants (in Spanish).docx Att 4(s) - Email to Participants - Spanish	IC Document
Att 5 (e) Privacy Policies.docx Att 5(e) - Privacy Policy -English	IC Document
Att 5 (s) Privacy Policies.docx Att 5(s) - Privacy Policy - Spanish	IC Document
Att 6 (e) Terms Of Use-Terms Conditions.docx Att 6(e) - Terms of Use - English	IC Document
Att 6 (s) Terms Of Use-Terms Conditions.docx Att 6(s) - Terms of Use - Spanish	IC Document
0920-0910_IC_4_Part A_2012_11_28.docx Supporting Statement A	IC Document
0920-0910_IC_4_Part B_2012 11 28.docx Supporting Statement B	IC Document

IC Title:

National Tobacco Education Campaign: Rough Cut Testing of TV, Print, and Radio Ads

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	none	Screener for General Pop. and AI/AN	Att 1(e) Screener-GenPop_AI-AN_2012_11_28.doc	Yes	Yes	Fillable Fileable
Form	none	Screener for Spanish Speaking Hispanics	Att 2(e) Screener_Spanish Speaking Hispanics (in English)_2012_11_28.doc	Yes	Yes	Fillable Fileable
Form	none	Screener for Spanish Speaking Hispanics - Spanish	Att 2(s) Screener_Spanish Speaking Hispanics (in Spanish)_2012_11_28.doc	Yes	Yes	Fillable Fileable
Form	none	Main Questionnaire - English	Att 3(e) Main Questionnaire (in English)_2012_11_28.doc	Yes	Yes	Fillable Fileable
Form	none	Main Questionnaire - Spanish	Att 3(s) Main Questionnaire (in Spanish)_2012_11_28.doc	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 21,900

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	21,900	21,900
Annual IC Time Burden (Hours)	2,050	2,050
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 4(e) - Email to Participants - English	Att 4(e) Emails To Participants (in English).docx	11/29/2012
Att 4(s) - Email to Participants - Spanish	Att 4(s) Emails To Participants (in Spanish).docx	11/29/2012
Att 5(e) - Privacy Policy -English	Att 5 (e) Privacy Policies.docx	11/29/2012
Att 5(s) - Privacy Policy - Spanish	Att 5 (s) Privacy Policies.docx	11/29/2012
Att 6(e) - Terms of Use - English	Att 6 (e) Terms Of Use-Terms Conditions.docx	11/29/2012
Att 6(s) - Terms of Use - Spanish	Att 6 (s) Terms Of Use-Terms Conditions.docx	11/29/2012
Supporting Statement A	0920-0910_IC_4_Part A_2012_11_28.docx	11/29/2012
Supporting Statement B	0920-0910_IC_4_Part B_2012 11 28.docx	11/29/2012

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