Information Collection

Hookah Purchase Journey: Online Hookah User Survey

IC 235192 under ICR 201907-0910-006 · OMB 0910-0810.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0910-0810 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment A - Consent Form.pdf	Other-Consent Form
Attachment B - Screener.pdf	Other-Screener
Attachment C - Questionnaire v2.docx	Other-Questionnaire
Part A - Quantitative Supporting Statement (General Market).pdf Part A - Quantitative Supporting Statement	IC Document
Part B - Quantitative Supporting Statement (General Market).pdf Part B - Quantitative Supporting Statement	IC Document
Attachment D- IRB approval_exemption.pdf IRB Approval Exemption	IC Document

IC Title:

Hookah Purchase Journey: Online Hookah User Survey

Agency IC Tracking Number:

CTP

IC Status: Unchanged

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-Consent Form	Attachment A - Consent Form.pdf	Yes	Yes	Fillable Printable
Other-Screener	Attachment B - Screener.pdf	Yes	Yes	Fillable Printable
Other-Questionnaire	Attachment C - Questionnaire v2.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: 5,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	5,000	5,000
Annual IC Time Burden (Hours)	1,390	1,390
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Part A - Quantitative Supporting Statement	Part A - Quantitative Supporting Statement (General Market).pdf	03/06/2019
Part B - Quantitative Supporting Statement	Part B - Quantitative Supporting Statement (General Market).pdf	03/06/2019
IRB Approval Exemption	Attachment D- IRB approval_exemption.pdf	03/06/2019

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