Information Collection

Developing Brand & Creative Concepts Designed to Prevent AI/AN Youth Tobacco Use

IC 236942 under ICR 201805-0910-001 · OMB 0910-0796.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0910-0796 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
App A.pdf	Other-Information Packet Materials
App A1.docx	Other-Parent_Guardian Permission For
App A2.docx	Other-Parent_Guardian Verbal Consent
App B.docx	Other-Participant Assent Form
App D.docx	Other-Moderator Guide
App C.pdf	Other-Screener
App D1.pdf	Other-Check-In Survey
App D2.pdf	Other-Brand Test Survey Versions A _
App D3.docx	Other-Creative Addendum
App D4.pdf	Other-Creative Concepts Survey
App A3.docx	Other-Parent_Guardian Opt-Out
Memo.docx Justification Memo	IC Document
IRB App.pdf IRB Approval	IC Document

IC Title:

Developing Brand & Creative 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-Information Packet Materials	App A.pdf	Yes	Yes	Fillable Fileable Signable
Other-Parent_Guardian Permission Form	App A1.docx	Yes	Yes	Fillable Printable
Other-Parent_Guardian Verbal Consent Script	App A2.docx	Yes	Yes	Fillable Fileable Signable
Other-Participant Assent Form	App B.docx	Yes	Yes	Fillable Printable
Other-Moderator Guide	App D.docx	Yes	No	Printable Only
Other-Screener	App C.pdf	Yes	No	Printable Only
Other-Check-In Survey	App D1.pdf	Yes	No	Fillable Fileable Signable
Other-Brand Test Survey Versions A _ B	App D2.pdf	Yes	Yes	Fillable Printable
Other-Creative Addendum	App D3.docx	Yes	Yes	Fillable Printable
Other-Creative Concepts Survey	App D4.pdf	Yes	Yes	Fillable Printable
Other-Parent_Guardian Opt-Out	App A3.docx	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 768

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	768	768
Annual IC Time Burden (Hours)	368	368
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Justification Memo	Memo.docx	07/19/2019
IRB Approval	IRB App.pdf	07/19/2019

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