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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.