Information Collection

Cognitive Testing of Questions on Teen Alcohol and Marijuana Use

IC 228379 under ICR 201506-0920-003 · OMB 0920-0222.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0222 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Cognitive Testing of Questions on Teen Alcohol and Marijuana Use	Form and Instruction
Telephone Screening Script- Cognitive Testing of Questio Att 3 Screening Script 090717.docx	Form and Instruction
Teen Alcohol and Marijuana Use Questions to be Cognitive Att 1 Teen AlcMarijuana Qs 090717.docx	Form and Instruction
10-day letter Teen Alcmarijuana 090717.docx 10-Day Letter Teen Alcoholand Marijuana Use Questions to be Cognitively Tested	IC Document
Att 2a&b Adv&flyer.docx Advertisement/Recruitment Flyer	IC Document
Att 4a-c ConsentAssent.docx Consent/Assent Form	IC Document
Att 5 Resp Data Collect Sheet.docx Respondent Data Collection Sheet	IC Document
Att 6 Thank You Letter.docx Thank You Letter	IC Document

IC Title:

Cognitive Testing of Questions on Teen Alcohol and Marijuana Use

Agency IC Tracking Number:

0920-0222-17BCH

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 and Instruction	NA	Telephone Screening Script- Cognitive Testing of Questions on Teen Alcohol and Marijuana Use	Att 3 Screening Script 090717.docx	NA	No		Paper Only
Form and Instruction	NA	Teen Alcohol and Marijuana Use Questions to be Cognitively Tested	Att 1 Teen AlcMarijuana Qs 090717.docx	NA	No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: Health and Demographic Surveys Conducted in Probablity Sampes of the U.S. Population 09-20-0164

FR Citation: 49 FR 37693

Number of Respondents: 78

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	78	78
Annual IC Time Burden (Hours)	34	34
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
10-Day Letter Teen Alcoholand Marijuana Use Questions to be Cognitively Tested	10-day letter Teen Alcmarijuana 090717.docx	09/19/2017
Advertisement/Recruitment Flyer	Att 2a&b Adv&flyer.docx	09/19/2017
Consent/Assent Form	Att 4a-c ConsentAssent.docx	09/19/2017
Respondent Data Collection Sheet	Att 5 Resp Data Collect Sheet.docx	09/19/2017
Thank You Letter	Att 6 Thank You Letter.docx	09/19/2017

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