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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
The Real Cost Smokeless: Wave 2 In-depth Interviews Designed to Prevent Rural Youth Tobacco Use
Agency IC Tracking Number:
CTP
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
Other-Screener
Attachment A - Screener.docx
Yes
Yes
Fillable Printable
Other-Parent Guardian Permission Form
Attachment B - Parent Guardian Permission.docx
No
Paper Only
Other-Parent Guardian Opt-out Form
Attachment C - Parent Guardian Opt-out.docx
No
Paper Only
Other-Youth Assent Form
Attachment D - Youth Assent Form.docx
No
Paper Only
Other-Discussion Guide
Attachment E - Discussion Guide.docx
No
Paper Only
Other-Google Map Example Center of Town
Attachment F - Map Example Center of Town.pdf
No
Printable Only
Other-Tobacco Product Image Boards
Attachment H - Tobacco Product Image Boards.pdf
No
Paper Only
Other-Interview Activity
Attachment I - Interview Activity.docx
No
Paper Only
Other-Google Map Example Entire Town
Attachment G - Map Example Entire Town.pdf
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:
88
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
88
0
88
0
0
0
Annual IC Time Burden (Hours)
54
0
54
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
OMB Memo
SMKLS W2 IDI OMB Memo.docx
12/12/2017
IRB Letter
Attachment J - IRB Letter.pdf
12/12/2017
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.