Youth Baseline Questionnaire (Male Rural Smokeless)

Evaluation of the Food and Drug Administration's General Market Youth Tobacco Prevention Campaign

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0910-0753 can be found here:

Documents and Forms

Document Name Document Type
5 Email_reminder1_ 0910-0753.doc Other-Email reminder #1
6 Email_reminder2_ 0910-0753.doc Other-E-mail reminder #2
7 Email_reminder3_ 0910-0753.doc Other-E-mail reminder #3
8 Attachment 6_Parent Permission 0910-0753.doc Other-Parent permission
9 Attachment 6_Youth Assent 0910-0753.doc Other-Youth Assent
12 Attachment 4_Media Tracking Screener and Instrument 0910-0753.doc Other-Media Tracking Screener and In
13 Rationale for Item Changes to the ExPECTT Media Tracking Instrument 0901-0753.docx Other-Rationale for Item Changes to

Information Collection (IC) Details

IC Title:	Youth Baseline Questionnaire (Male Rural Smokeless)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Email reminder #1	5 Email_reminder1_ 0910-0753.doc	Yes	No	Printable Only
Other-E-mail reminder #2	6 Email_reminder2_ 0910-0753.doc	Yes	No	Printable Only
Other-E-mail reminder #3	7 Email_reminder3_ 0910-0753.doc	Yes	No	Printable Only
Other-Parent permission	8 Attachment 6_Parent Permission 0910-0753.doc	Yes	No	Printable Only
Other-Youth Assent	9 Attachment 6_Youth Assent 0910-0753.doc	Yes	No	Printable Only
Other-Media Tracking Screener and Instrument	12 Attachment 4_Media Tracking Screener and Instrument 0910-0753.doc	Yes	No	Printable Only
Other-Rationale for Item Changes to Media Tracking Instrument	13 Rationale for Item Changes to the ExPECTT Media Tracking Instrument 0901-0753.docx	Yes	No	Printable Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 656	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	656	656
Annual IC Time Burden (Hours)	328	328
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.