Screening and Consent (English and Spanish)

Extended Evaluation of the National Tobacco Prevention and Control Public Education Campaign

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1083 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-1083 Screening and Consent (English and Spanish) Form and Instruction
0920-1083 Screening and Consent Attachment C-1. Screening & Consent Screenshots 12-5-18 (English).pdf Form and Instruction
0920-1083 Screener and Consent Spanish Attachment C-2. Screening & Consent Screenshots 6-10-19 (Spanish).pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Screening and Consent (English and Spanish)	Agency IC Tracking Number:	15PI

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 and Instruction	0920-1083	Screener and Consent Spanish	Attachment C-2. Screening & Consent Screenshots 6-10-19 (Spanish).pdf		Yes	Yes	Fillable Fileable
Form and Instruction	0920-1083	Screening and Consent	Attachment C-1. Screening & Consent Screenshots 12-5-18 (English).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 16,667	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	16,667	-8,333	25,000
Annual IC Time Burden (Hours)	1,389	-694	2,083
Annual IC Cost Burden (Dollars)	32,501	-16,249	48,750

Documents for IC

Title	Document	Date Uploaded
No associated records found

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