Screening and Consent

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

Documents and Forms

Document Name Document Type
Form 0920-1083 Screening and Consent Form and Instruction
0920-1083 Screening and Consent Attachment C. Screening & Consent Questionaire Screenshots.pdf Form and Instruction
0920-1083 Screening and Consent Attachment C. Screening & Consent Questionaire Screenshots.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Screening and Consent	Agency IC Tracking Number:	0920-1083

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	Screening and Consent	Attachment C. Screening & Consent Questionaire Screenshots.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	Previously Approved
Annual Number of Responses for this IC	16,667	16,667
Annual IC Time Burden (Hours)	1,389	1,389
Annual IC Cost Burden (Dollars)	32,501	32,501

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.