Information Collection

National Youth Tobacco Survey 2017 Questionnaire

IC 185555 under ICR 201609-0920-015 · OMB 0920-0621.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0621 can be found here:

Documents and Forms

Document Name Document Type
Form Attachment I-1 National Youth Tobacco Survey 2017 Questionnaire Form
Attachment I-1 NYTS 2017 Questionnaire 2017_NYTS_Draft_Instrument_final draft.docx Form
Attachment I2_Parental Permission Form Distribution Script.doc Parental Permission Distribution Script IC Document
Attachment I3_Parental Permission Form and Fact Sheet (English Version).doc Parental Permission and Fact Sheet IC Document
Attachment I4_Parental Permission Form and Fact Sheet (Spanish Version).doc Parental Permission and Fact Sheet - Spanish IC Document
Attachment I5_Parental Permission Form Reminder Notice (English Version).doc Parental Permission Reminder - English IC Document
Attachment I6_Parental Permission Form Reminder Notice (Spanish Version).doc Parental Permission Reminder - Spanish IC Document
Attachment I7_Questionnaire Administration Script.doc Questionnaire Administration Script IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	National Youth Tobacco Survey 2017 Questionnaire	Agency IC Tracking Number:	15EA

Is this a Common Form? No		IC Status: Modified

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	Attachment I-1	NYTS 2017 Questionnaire	2017_NYTS_Draft_Instrument_final draft.docx		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 20,077	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	20,077	20,077
Annual IC Time Burden (Hours)	15,058	15,058
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Parental Permission Distribution Script	Attachment I2_Parental Permission Form Distribution Script.doc	12/15/2014
Parental Permission and Fact Sheet	Attachment I3_Parental Permission Form and Fact Sheet (English Version).doc	12/15/2014
Parental Permission and Fact Sheet - Spanish	Attachment I4_Parental Permission Form and Fact Sheet (Spanish Version).doc	12/15/2014
Parental Permission Reminder - English	Attachment I5_Parental Permission Form Reminder Notice (English Version).doc	12/15/2014
Parental Permission Reminder - Spanish	Attachment I6_Parental Permission Form Reminder Notice (Spanish Version).doc	12/15/2014
Questionnaire Administration Script	Attachment I7_Questionnaire Administration Script.doc	12/15/2014

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