Information Collection

Quanitative Study of Youth Reactions to Rough-Cut Advertising to Prevent Youth Tobacco Use Among Multicultural Youth

IC 212999 under ICR 201406-0910-011 · OMB 0910-0674.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Electronic Screener.doc	Instruction
Parental Consent Form.docx	Instruction
Parental Opt-Out.docx	Instruction
Participant Assent Form.doc	Instruction
Questionnaire.docx	Instruction
Rough Cut Video Ad Stimuli.doc	Other-Ad Stimuli
OMB Justification Memo Copy Testing.docx OMB Justification Memo	IC Document

IC Title:

Agency IC Tracking Number:

CTP

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction	Electronic Screener.doc	Yes	Yes	Fillable Printable
Instruction	Parental Consent Form.docx	Yes	Yes	Fillable Printable
Instruction	Parental Opt-Out.docx	Yes	Yes	Fillable Printable
Instruction	Participant Assent Form.doc	Yes	Yes	Fillable Printable
Instruction	Questionnaire.docx	Yes	Yes	Fillable Printable
Other-Ad Stimuli	Rough Cut Video Ad Stimuli.doc	Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,230

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	4,230	4,230
Annual IC Time Burden (Hours)	1,079	1,079
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
OMB Justification Memo	OMB Justification Memo Copy Testing.docx	09/15/2014

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