Information Collection

The Real Cost Smokeless: Wave 2 In-depth Interviews Designed to Prevent Rural Youth Tobacco Use

IC 229407 under ICR 201411-0910-007 · OMB 0910-0796.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0910-0796 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment A - Screener.docx	Other-Screener
Attachment B - Parent Guardian Permission.docx	Other-Parent Guardian Permission For
Attachment C - Parent Guardian Opt-out.docx	Other-Parent Guardian Opt-out Form
Attachment D - Youth Assent Form.docx	Other-Youth Assent Form
Attachment E - Discussion Guide.docx	Other-Discussion Guide
Attachment F - Map Example Center of Town.pdf	Other-Google Map Example Center of T
Attachment H - Tobacco Product Image Boards.pdf	Other-Tobacco Product Image Boards
Attachment I - Interview Activity.docx	Other-Interview Activity
Attachment G - Map Example Entire Town.pdf	Other-Google Map Example Entire Town
SMKLS W2 IDI OMB Memo.docx OMB Memo	IC Document
Attachment J - IRB Letter.pdf IRB Letter	IC Document

IC Title:

The Real Cost Smokeless: Wave 2 In-depth Interviews Designed to Prevent Rural Youth Tobacco Use

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-Screener	Attachment A - Screener.docx	Yes	Yes	Fillable Printable
Other-Parent Guardian Permission Form	Attachment B - Parent Guardian Permission.docx	No		Paper Only
Other-Parent Guardian Opt-out Form	Attachment C - Parent Guardian Opt-out.docx	No		Paper Only
Other-Youth Assent Form	Attachment D - Youth Assent Form.docx	No		Paper Only
Other-Discussion Guide	Attachment E - Discussion Guide.docx	No		Paper Only
Other-Google Map Example Center of Town	Attachment F - Map Example Center of Town.pdf	No		Printable Only
Other-Tobacco Product Image Boards	Attachment H - Tobacco Product Image Boards.pdf	No		Paper Only
Other-Interview Activity	Attachment I - Interview Activity.docx	No		Paper Only
Other-Google Map Example Entire Town	Attachment G - Map Example Entire Town.pdf	No		Printable Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 88

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	88	88
Annual IC Time Burden (Hours)	54	54
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
OMB Memo	SMKLS W2 IDI OMB Memo.docx	12/12/2017
IRB Letter	Attachment J - IRB Letter.pdf	12/12/2017

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