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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
LGBT Campaign: Wave 1B Online Quantitative Study Designed to Prevent Young Adult Tobacco Use
Agency IC Tracking Number:
CTP
IC Status:
Unchanged
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
Other-Screener
Attachment A_Screener (+++).docx
Yes
Yes
Fillable Fileable
Other-Questionnaire
Attachment B_Questionnaire (+++).docx
Yes
Yes
Fillable Fileable
Other-Informed Consent Form
Attachment C_Informed Consent Form (+++).docx
Yes
Yes
Fillable Fileable
Other-Reminder Emails
Attachment D_Reminder Emails (+++).docx
Yes
No
Printable Only
Other-Social Media Ads
Attachment E_Social Media Ads (++).pdf
Yes
No
Printable Only
Other-Video Ad Stimuli
Attachment F_Video Ad Stimuli.doc
Yes
No
Printable Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Consumer Health and Safety
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
3,150
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Requested
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
3,150
0
0
0
0
3,150
Annual IC Time Burden (Hours)
427
0
0
0
0
427
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Supporting Statement A
LGBT Campaign GenIC_Part A_Quantitative Supporting Statement (TFL)_OMB+++.docx
01/04/2017
Supporting Statement B
Part B_Quantitative Supporting Statement (TFL) (+++).docx
01/04/2017
IRB Letter
Attachment G_IRB Letter.pdf
01/04/2017
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.