Information Collection

FDA Tobacco Prevention Broad Quantitative Research Package (CTP)

IC 239960 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⚠️ Notice: This information collection may be referencing outdated material.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_Parental Notification and Opt-Out.docx	Other-Parental Notification and Opt-
Attachment A1_Email Invite.docx	Other-Email Invitation
Attachment B_ Youth Assent Form.docx	Other-Youth Assent Form
Attachment C - Adult Participant Consent Form.docx	Other-Adult Consent Form
Attachment D_ Youth Screener.docx	Other-Youth Screener
Attachment E_ Adult Screener.docx	Other-Adult Screener
Attachment F_Youth Questionnaire.docx	Other-Survey Instrument
Attachment G_Adult Questionnaire.docx	Other-Adult Survey Instrument
STIMULI_03232020.docx	Other-Stimuli
0810 Supporting Statement Part A Tobacco Prevention Broad Quantitative Research 2020.docx 0810 Supporting Statement Part A	IC Document
0810 Supporting Statement Part B Tobacco Prevention Broad QR 2020.docx 0810 Supporting Statement Part B	IC Document
Attachment I_ IRB Letter.pdf IRB Approval Letter	IC Document

IC Title:

FDA Tobacco Prevention Broad Quantitative Research Package (CTP)

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-Parental Notification and Opt-Out	Attachment A_Parental Notification and Opt-Out.docx	Yes	No	Printable Only
Other-Email Invitation	Attachment A1_Email Invite.docx	Yes	No	Printable Only
Other-Youth Assent Form	Attachment B_ Youth Assent Form.docx	Yes	Yes	Fillable Fileable
Other-Adult Consent Form	Attachment C - Adult Participant Consent Form.docx	Yes	Yes	Fillable Fileable
Other-Youth Screener	Attachment D_ Youth Screener.docx	Yes	Yes	Fillable Fileable
Other-Adult Screener	Attachment E_ Adult Screener.docx	Yes	Yes	Fillable Fileable
Other-Survey Instrument	Attachment F_Youth Questionnaire.docx	Yes	Yes	Fillable Fileable
Other-Adult Survey Instrument	Attachment G_Adult Questionnaire.docx	Yes	Yes	Fillable Fileable
Other-Stimuli	STIMULI_03232020.docx	Yes	No	Printable Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 22,000

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	22,000	22,000
Annual IC Time Burden (Hours)	5,596	5,596
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
0810 Supporting Statement Part A	0810 Supporting Statement Part A Tobacco Prevention Broad Quantitative Research 2020.docx	02/13/2020
0810 Supporting Statement Part B	0810 Supporting Statement Part B Tobacco Prevention Broad QR 2020.docx	02/13/2020
IRB Approval Letter	Attachment I_ IRB Letter.pdf	02/13/2020

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