Survey Screener Questionnaire

[NCCDPHP] Menthol-Flavored Tobacco Products Policy Evaluation

Documents and Forms

Document Name Document Type
Form 0920-23FN Survey Screener Questionnaire Form
0920-23FN Survey Eligibility Screener Screener 7. Attatchment 4a. Survey Eligibility Screener Screener_Menthol Policy Evaluation.docx Form

Information Collection (IC) Details

IC Title:	Survey Screener Questionnaire	Agency IC Tracking Number:	0920-23FN

Is this a Common Form? No		IC Status: New

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	0920-23FN	Survey Eligibility Screener Screener	7. Attatchment 4a. Survey Eligibility Screener Screener_Menthol Policy Evaluation.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 9,800	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	9,800	9,800
Annual IC Time Burden (Hours)	327	327
Annual IC Cost Burden (Dollars)	0	0

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.