Screening and Consent Process (Phase 2Survey)

Evaluation of the National Tobacco Prevention and Control Public Education Campaign

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0923 can be found here:

Documents and Forms

Document Name Document Type
Screening and Consent Process (Phase 2Survey) Form and Instruction
Evaluation of the National Tobacco Prevention and Contro Att E-1. Revised Screener 6-11-13.docx Form and Instruction
Att F-1. KN Recruitment Procedures.DOC Att F-1. KN Recruitment Procedures IC Document
Att E-2. Email Notification and Reminders.doc Att E-2. Email Notification and Reminders IC Document

Information Collection (IC) Details

IC Title:	Screening and Consent Process (Phase 2Survey)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	None	Evaluation of the National Tobacco Prevention and Control Public Education Screening Questionnaire	Att E-1. Revised Screener 6-11-13.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 43,737	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	43,737	43,737
Annual IC Time Burden (Hours)	1,458	1,458
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att F-1. KN Recruitment Procedures	Att F-1. KN Recruitment Procedures.DOC	02/07/2013
Att E-2. Email Notification and Reminders	Att E-2. Email Notification and Reminders.doc	02/04/2013

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