Information Collection

LGBT Young Adult Tobacco Use Prevention Campaign: Copy Testing

IC 218027 under ICR 201406-0910-011 · OMB 0910-0674.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
LGBT Copy Consent.docx	Other-Consent
LGBT Copy Electronic Screener.docx	Other-Electronic Screener
LGBT Copy Paper Screener.pdf	Other-Paper Screener
LGBT Copy Questionnaire.docx	Other-Questionnaire
LGBT Copy Stimuli.docx	Other-Stimuli
OMB Justification Memo_LGBT.docx Memo - Supporting Statement	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
Other-Consent	LGBT Copy Consent.docx	Yes	Yes	Fillable Fileable
Other-Electronic Screener	LGBT Copy Electronic Screener.docx	Yes	Yes	Fillable Fileable
Other-Paper Screener	LGBT Copy Paper Screener.pdf	No		Printable Only
Other-Questionnaire	LGBT Copy Questionnaire.docx	Yes	Yes	Fillable Fileable
Other-Stimuli	LGBT Copy Stimuli.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 11,500

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 Agency Discretion
Annual Number of Responses for this IC	11,500	11,500
Annual IC Time Burden (Hours)	1,278	1,278
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Memo - Supporting Statement	OMB Justification Memo_LGBT.docx	08/26/2015

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