Information Collection

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

IC 231650 under ICR 201911-0910-015 · 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⚠️ Notice: This information collection may be referencing outdated material.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: 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-Check-In Survey	Attachment G - Check-In Survey.pdf	No		Paper Only
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-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
	Requested	Previously Approved
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.