Information Collection

Youth Baseline Questionnaire (Male Rural Smokeless)

IC 208710 under ICR 201502-0910-009 · OMB 0910-0753.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0910-0753 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
5 Email_reminder1_ 0910-0753.doc	Other-Email reminder #1
6 Email_reminder2_ 0910-0753.doc	Other-E-mail reminder #2
7 Email_reminder3_ 0910-0753.doc	Other-E-mail reminder #3
8 Attachment 6_Parent Permission 0910-0753.doc	Other-Parent permission
9 Attachment 6_Youth Assent 0910-0753.doc	Other-Youth Assent
12 Attachment 4_Media Tracking Screener and Instrument 0910-0753.doc	Other-Media Tracking Screener and In
13 Rationale for Item Changes to the ExPECTT Media Tracking Instrument 0901-0753.docx	Other-Rationale for Item Changes to

IC Title:

Youth Baseline Questionnaire (Male Rural Smokeless)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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-Email reminder #1	5 Email_reminder1_ 0910-0753.doc	Yes	No	Printable Only
Other-E-mail reminder #2	6 Email_reminder2_ 0910-0753.doc	Yes	No	Printable Only
Other-E-mail reminder #3	7 Email_reminder3_ 0910-0753.doc	Yes	No	Printable Only
Other-Parent permission	8 Attachment 6_Parent Permission 0910-0753.doc	Yes	No	Printable Only
Other-Youth Assent	9 Attachment 6_Youth Assent 0910-0753.doc	Yes	No	Printable Only
Other-Media Tracking Screener and Instrument	12 Attachment 4_Media Tracking Screener and Instrument 0910-0753.doc	Yes	No	Printable Only
Other-Rationale for Item Changes to Media Tracking Instrument	13 Rationale for Item Changes to the ExPECTT Media Tracking Instrument 0901-0753.docx	Yes	No	Printable Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 656

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	Previously Approved
Annual Number of Responses for this IC	656	656
Annual IC Time Burden (Hours)	328	328
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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