Information Collection

Developing Strategic Concepts Designed to Prevent AI/AN Youth Tobacco Use

IC 231650 under ICR 201707-0910-018 · OMB 0910-0497.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0910-0497 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment A - Screener with Recruiter Notes.pdf	Other-Screener
Attachment B - Parent Guardian Permission Form.pdf	Other-Parent Guardian Permission For
Attachment C - Parental Permission Verbal Script.pdf	Other-Parental Permission Verbal Scr
Attachment D - Participant Assent.pdf	Other-Participant Assent
Attachment E - Moderator Guide.pdf	Other-Moderator Guide
Attachment F - Individual Picture Sort Deck.pdf	Other- Individual Picture Sort Deck
Attachment G - Check-In Survey.pdf	Other-Check-In Survey
Attachment H - ID Projection.pdf	Other-ID Projection
Attachment I - Video Stimuli.pdf	Other-Video Stimuli
AIAN SC OMB Memo.docx AIAN SC OMB Memo	IC Document
Attachment J - IRB Letter.pdf IRB Letter	IC Document

IC Title:

Developing Strategic Concepts Designed to Prevent AI/AN Youth Tobacco Use

Agency IC Tracking Number:

CTP

IC Status: New

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-Screener	Attachment A - Screener with Recruiter Notes.pdf	No		Printable Only
Other-Parent Guardian Permission Form	Attachment B - Parent Guardian Permission Form.pdf	No		Paper Only
Other-Parental Permission Verbal Script	Attachment C - Parental Permission Verbal Script.pdf	No		Printable Only
Other-Participant Assent	Attachment D - Participant Assent.pdf	No		Paper Only
Other-Moderator Guide	Attachment E - Moderator Guide.pdf	No		Printable Only
Other- Individual Picture Sort Deck	Attachment F - Individual Picture Sort Deck.pdf	Yes	No	Printable Only
Other-Check-In Survey	Attachment G - Check-In Survey.pdf	No		Paper Only
Other-ID Projection	Attachment H - ID Projection.pdf	Yes	No	Printable Only
Other-Video Stimuli	Attachment I - Video Stimuli.pdf	Yes	No	Printable Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 672

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	672	672
Annual IC Time Burden (Hours)	322	322
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
AIAN SC OMB Memo	AIAN SC OMB Memo.docx	06/05/2018
IRB Letter	Attachment J - IRB Letter.pdf	06/05/2018

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