Information Collection

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

IC 236942 under ICR 202002-0910-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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: 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-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
	Requested	Previously Approved
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.