Information Collection

P7. Cognitive Testing Participant SCREENER

IC 229816 under ICR 202005-0920-005 · OMB 0920-0621.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0621 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0621 P7. Cognitive Testing Participant SCREENER	Form
0920-0621 Youth Cogntive Testing Screener Attachment Q6. Youth Cogntive Testing Screener_revised.docx	Form
P2_Youth Under 18 Assent Form_4.16.2018_CLEAN_2.docx P2. Cognitive Interview Assent Form	IC Document
P3_Youth 18 yo Consent_4.16.2018_CLEAN_2.docx P3. Cognitive Interview Consent Form	IC Document
P4_Youth Under 18 Parental Permission_4.16.2018 rbk_IA_AG_CLEAN_2.docx P4. Cognitive Testing Parental Permission	IC Document
P5_Youth Materials_ENDS Key Facts_no_tracked_changes.pdf P5. Youth Materials: ENDS KEY FACTS	IC Document
P6_Youth Materials_Tools for Quitting_no_tracked_changes.pdf P6. Youth Matrerials: smokefreeteen Tools for Quitting	IC Document

IC Title:

P7. Cognitive Testing Participant SCREENER

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	0920-0621	Youth Cogntive Testing Screener	Attachment Q6. Youth Cogntive Testing Screener_revised.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 285

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	Previously Approved
Annual Number of Responses for this IC	285	-15	300
Annual IC Time Burden (Hours)	38	-2	40
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
P2. Cognitive Interview Assent Form	P2_Youth Under 18 Assent Form_4.16.2018_CLEAN_2.docx	04/25/2018
P3. Cognitive Interview Consent Form	P3_Youth 18 yo Consent_4.16.2018_CLEAN_2.docx	04/25/2018
P4. Cognitive Testing Parental Permission	P4_Youth Under 18 Parental Permission_4.16.2018 rbk_IA_AG_CLEAN_2.docx	04/25/2018
P5. Youth Materials: ENDS KEY FACTS	P5_Youth Materials_ENDS Key Facts_no_tracked_changes.pdf	04/25/2018
P6. Youth Matrerials: smokefreeteen Tools for Quitting	P6_Youth Materials_Tools for Quitting_no_tracked_changes.pdf	04/25/2018

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