Information Collection

Rough Cut Testing for the 2016 Tips Campaign

IC 216586 under ICR 201412-0920-008 · OMB 0920-0910.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.