Rough Cut Testing for the 2016 Tips Campaign

Message Testing for Tobacco Communication Activities

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Rough Cut Testing for the 2016 Tips Campaign Form
Screener Att 1a_ScreenerQuestionnaire Tips 2016 v16 FINAL.docx Form
Survey Screenshots Att 4 Screenshots English v16 FINAL.pdf Form
GenIC 15_Part A_5 12 2015.docx SS Part A IC Document
GenIC 15_Part B_5 12 2015.docx SS Part B IC Document
Att 1c Chinese ScreenerQuestionnaire Tips 2016 v16 FINAL.docx Chinese Screener IC Document
Att 5 Screenshots_Chinese v16 FINAL.pdf Chinese Survey Screenshots IC Document
Att 2_Email Recruitment Rough Cut Tests v16 FINAL.docx Email Recruitment IC Document
Att 3_Terms and Conditions v16 FINAL.docx Terms and Conditions IC Document
Att 1b_MainQuestionnaire Tips 2016 v16 FINAL.docx Word version Survey IC Document
Att 1d_Chinese MainQuestionnaire 2016 v16 FINAL.docx Chinese Word Version Survey IC Document

Information Collection (IC) Details

IC Title:	Rough Cut Testing for the 2016 Tips Campaign	Agency IC Tracking Number:	15AIT

IC Status: New

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	none	Screener	Att 1a_ScreenerQuestionnaire Tips 2016 v16 FINAL.docx		Yes	Yes	Fillable Fileable
Form	none	Survey Screenshots	Att 4 Screenshots English v16 FINAL.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 13,650	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	13,650	13,650
Annual IC Time Burden (Hours)	4,110	4,110
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SS Part A	GenIC 15_Part A_5 12 2015.docx	05/13/2015
SS Part B	GenIC 15_Part B_5 12 2015.docx	05/13/2015
Chinese Screener	Att 1c Chinese ScreenerQuestionnaire Tips 2016 v16 FINAL.docx	05/13/2015
Chinese Survey Screenshots	Att 5 Screenshots_Chinese v16 FINAL.pdf	05/13/2015
Email Recruitment	Att 2_Email Recruitment Rough Cut Tests v16 FINAL.docx	05/13/2015
Terms and Conditions	Att 3_Terms and Conditions v16 FINAL.docx	05/13/2015
Word version Survey	Att 1b_MainQuestionnaire Tips 2016 v16 FINAL.docx	05/13/2015
Chinese Word Version Survey	Att 1d_Chinese MainQuestionnaire 2016 v16 FINAL.docx	05/13/2015

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