Screener and Consent

Extended Evaluation of the National Tobacco Prevention and Control Public Education Campaign

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1083 can be found here:

Documents and Forms

Document Name Document Type
Screener and Consent Form and Instruction
Screening and Consent Questionnaire Att C. Screening & Consent Questionnaire - English and Spanish_061515.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Screener and Consent	Agency IC Tracking Number:	15PI

Is this a Common Form? No		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	none	Screening and Consent Questionnaire	Att C. Screening & Consent Questionnaire - English and Spanish_061515.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 25,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	25,000	25,000
Annual IC Time Burden (Hours)	2,083	2,083
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.