View Information Collection (IC)

View Information Collection (IC)

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:

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

Federal Enterprise Architecture Business Reference Module

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 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	285	0	-15	0	0	300
Annual IC Time Burden (Hours)	38	0	-2	0	0	40
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

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.