Information Collection

Rough Cut Testing of Spanish, Chinese, Korean, and Vietnamese Print Advertisements for the 2015 Tips Campaign

IC 213871 under ICR 201312-0920-001 · OMB 0920-0910.

⚠️ Notice: This information collection may be referencing outdated material.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

2025-03-28 - No material or nonsubstantive change to a currently approved collection
2024-09-24 - No material or nonsubstantive change to a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Rough Cut Testing of Spanish, Chinese, Korean, and Vietnamese Print Advertisements for the 2015 Tips Campaign	Form
Screener in Chinese Attachment 1a(C) Screener Chinese 10272014.pdf	Form
Screener in Korean Attachment 1a(K) Screener Questionnaire Korean 10272014.pdf	Form
Screener in Spanish Attachment 1a(S) Screener Spanish 10272014.pdf	Form
Screener in Vietnamese Attachment 1a(V) Screener Vietnamese 10272014.pdf	Form
Main Questionnaire in Chinese Attachment 1b(C) Questionnaire Chinese 10272014.pdf	Form
Main Questionnaire in Korean Attachment 1b(K) Questionnaire Korean 10272014.pdf	Form
Main Questionnaire in Spanish Attachment 1b(S) Questionnaire Spanish 10272014.pdf	Form
Main Questionnaire in Vietnamese Attachment 1b(V) Questionnaire Vietnamese 10272014.pdf	Form
GenIC 14_Part A 11042014.docx SS Part A	IC Document
GenIC 14_Part B 11042014.docx SS Part B	IC Document
Attachment 2(C) Initial Email Invitation Chinese 10272014.pdf Email Invitation Chinese	IC Document
Attachment 2(K) Initial Email Invitation Korean 10272014.pdf Email Invitation Korean	IC Document
Attachment 2(S) Initial Email Invitation Spanish 10272014.pdf Email Invitation Spanish	IC Document
Attachment 2(V) Initial Email Invitation Vietnamese 10272014.pdf Email Invitation Vietnamese	IC Document
Attachment 3(S) Privacy Policy Spanish 10272014.pdf Toluna Privacy Policy Spanish	IC Document
Attachment 3(C) Privacy Policy Chinese 10272014.pdf Toluna Privacy Policy Chinese	IC Document
Attachment 3(K) Privacy Policy Korean 10272014.pdf Toluna Privacy Policy Korean	IC Document
Attachment 3(V) Toluna Privacy Policy Vietnamese 10272014.pdf Toluna Privacy Policy Vietnamese	IC Document
Attachment 4(C) Terms and Conditions Chinese 10272014.pdf Terms and conditions Chinese	IC Document
Attachment 4(K) Terms and Conditions Korean 10272014.pdf Terms and Conditions Korean	IC Document
Attachment 4(S) Terms and Conditions Spanish 10272014.pdf Terms and Conditions Spanish	IC Document
Attachment 4(V) Terms and Conditions Vietnamese 10272014.pdf Terms and Conditions Vietnamese	IC Document
Attachment 5(S) Screen Shots in Spanish 10272014.pdf Annotated Screen Shots in Spanish	IC Document
Attachment 5(C) Screen Shots in Chinese 10272014.pdf Annotated Screenshots in Chinese	IC Document
Attachment 5(K) Screen Shots in Korean 10272014.pdf Annotated Screenshots in Korean	IC Document
Attachment 5(V) Screen Shots in Vietnamese 10272014.pdf Annotated Screenshots in Vietnamese	IC Document
Att 1a(E)_Screener English.docx Screener in English	IC Document
Att 1b_MainQuestionnaire Tips 2015 v10.docx Main Questionnaire in English	IC Document
Att 2(E)_Email Recruitment Rough Cut Tests English.docx Email Recruitment in English	IC Document
Att 3(E)_Privacy Policy English.docx Toluna Privacy Policy in English	IC Document
Att 4(E)_Terms and Conditions English.docx Toluna Terms and Conditions in English	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Rough Cut Testing of Spanish, Chinese, Korean, and Vietnamese Print Advertisements for the 2015 Tips Campaign

Agency IC Tracking Number:

15DT

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	none	Screener in Chinese	Attachment 1a(C) Screener Chinese 10272014.pdf	Yes	Yes	Fillable Fileable
Form	none	Screener in Korean	Attachment 1a(K) Screener Questionnaire Korean 10272014.pdf	Yes	Yes	Fillable Fileable
Form	none	Screener in Spanish	Attachment 1a(S) Screener Spanish 10272014.pdf	Yes	No	Fillable Fileable
Form	none	Screener in Vietnamese	Attachment 1a(V) Screener Vietnamese 10272014.pdf	Yes	Yes	Fillable Fileable
Form	none	Main Questionnaire in Chinese	Attachment 1b(C) Questionnaire Chinese 10272014.pdf	Yes	Yes	Fillable Fileable
Form	none	Main Questionnaire in Korean	Attachment 1b(K) Questionnaire Korean 10272014.pdf	Yes	Yes	Fillable Fileable
Form	none	Main Questionnaire in Spanish	Attachment 1b(S) Questionnaire Spanish 10272014.pdf	Yes	Yes	Fillable Fileable
Form	none	Main Questionnaire in Vietnamese	Attachment 1b(V) Questionnaire Vietnamese 10272014.pdf	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,648

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	4,648	4,648
Annual IC Time Burden (Hours)	684	684
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SS Part A	GenIC 14_Part A 11042014.docx	11/13/2014
SS Part B	GenIC 14_Part B 11042014.docx	11/13/2014
Email Invitation Chinese	Attachment 2(C) Initial Email Invitation Chinese 10272014.pdf	11/13/2014
Email Invitation Korean	Attachment 2(K) Initial Email Invitation Korean 10272014.pdf	11/13/2014
Email Invitation Spanish	Attachment 2(S) Initial Email Invitation Spanish 10272014.pdf	11/13/2014
Email Invitation Vietnamese	Attachment 2(V) Initial Email Invitation Vietnamese 10272014.pdf	11/13/2014
Toluna Privacy Policy Spanish	Attachment 3(S) Privacy Policy Spanish 10272014.pdf	11/13/2014
Toluna Privacy Policy Chinese	Attachment 3(C) Privacy Policy Chinese 10272014.pdf	11/13/2014
Toluna Privacy Policy Korean	Attachment 3(K) Privacy Policy Korean 10272014.pdf	11/13/2014
Toluna Privacy Policy Vietnamese	Attachment 3(V) Toluna Privacy Policy Vietnamese 10272014.pdf	11/13/2014
Terms and conditions Chinese	Attachment 4(C) Terms and Conditions Chinese 10272014.pdf	11/13/2014
Terms and Conditions Korean	Attachment 4(K) Terms and Conditions Korean 10272014.pdf	11/13/2014
Terms and Conditions Spanish	Attachment 4(S) Terms and Conditions Spanish 10272014.pdf	11/13/2014
Terms and Conditions Vietnamese	Attachment 4(V) Terms and Conditions Vietnamese 10272014.pdf	11/13/2014
Annotated Screen Shots in Spanish	Attachment 5(S) Screen Shots in Spanish 10272014.pdf	11/13/2014
Annotated Screenshots in Chinese	Attachment 5(C) Screen Shots in Chinese 10272014.pdf	11/13/2014
Annotated Screenshots in Korean	Attachment 5(K) Screen Shots in Korean 10272014.pdf	11/13/2014
Annotated Screenshots in Vietnamese	Attachment 5(V) Screen Shots in Vietnamese 10272014.pdf	11/13/2014
Screener in English	Att 1a(E)_Screener English.docx	11/13/2014
Main Questionnaire in English	Att 1b_MainQuestionnaire Tips 2015 v10.docx	11/13/2014
Email Recruitment in English	Att 2(E)_Email Recruitment Rough Cut Tests English.docx	11/13/2014
Toluna Privacy Policy in English	Att 3(E)_Privacy Policy English.docx	11/13/2014
Toluna Terms and Conditions in English	Att 4(E)_Terms and Conditions English.docx	11/13/2014

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