Document Name Document Type
Formative Research with Consumers, Couples, and Innovators about Reproductive Life Planning and Preconception Health Form
Couples - Interview guide Attachment 3 - Couples Interview Guide_6.24.10.doc Form
Couples -screener Attachment 7 - Couples Screening Instrument__6.24.10.doc Form
Couples - Consent form Attachment 10 - Couples Consent Form_6.24.10.doc Form
Women consumers - Screener Attachment 6 - Consumer Screening Instrument rev 6.2.10.doc Form
Women consumers - Consent form Attachment 9 - Consumer Consent Form_psg.doc Form
Women consumers - Focus group guide Attachment 2 - Consumer Focus Group Guide_psg.doc Form
Women consumers - Demographic questionnaire Attachment 5 - Consumer Demographic Questionnaire_rev 3.17.10.doc Form
Innovator - Consent form Attachment 11 - Innovator Consent Form_psg.doc Form
Innovator - Interview guide Attachment 4 - Innovator Interview Guide rev 3-17.10.doc Form
Attachment 1.pdf Attachment 1 - Legislative authority IC Document
Attachment 8 - Letter from recruitment firm.pdf Attachment 8 - Recruitment firm letter IC Document
Attachment 12 - Consumer Confirmation Email.doc Attachment 12 - Consumer email IC Document
Attachment 13 - Couples Confirmation Letter_6.24.10.doc Attachment 13 - Couples letter IC Document
Attachment 14 - Innovator Confirmation Email.doc Attachment 14 - Innovator email IC Document
Attachment 15 - IRB Approval Notice (consumer FGs and stakeholder interviews).Full.pdf Attachment 15 - Consumer IRB approval IC Document
Attachment 16 - IRB Approval Notice (couple interviews).pdf Attachment 16 - Couples IRB approval IC Document
Projects 1 & 2 OMB ap Section A_rev 06.24.10.doc Supporting statement IC Document
Pappas-Deluca et al.pdf Literature - recruitment IC Document
Preloran et al.pdf Literature - incentives IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Formative Research with Consumers, Couples, and Innovators about Reproductive Life Planning and Preconception Health	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Innovator - Interview guide	Attachment 4 - Innovator Interview Guide rev 3-17.10.doc	No	No	Paper Only
Form	none	Women consumers - Consent form	Attachment 9 - Consumer Consent Form_psg.doc	No	No	Paper Only
Form	none	Women consumers - Focus group guide	Attachment 2 - Consumer Focus Group Guide_psg.doc	No	No	Paper Only
Form	none	Women consumers - Demographic questionnaire	Attachment 5 - Consumer Demographic Questionnaire_rev 3.17.10.doc	No	No	Paper Only
Form	none	Innovator - Consent form	Attachment 11 - Innovator Consent Form_psg.doc	No	No	Paper Only
Form	none	Couples - Interview guide	Attachment 3 - Couples Interview Guide_6.24.10.doc	No	No	Paper Only
Form	none	Couples -screener	Attachment 7 - Couples Screening Instrument__6.24.10.doc	No	No	Paper Only
Form	none	Couples - Consent form	Attachment 10 - Couples Consent Form_6.24.10.doc	No	No	Paper Only
Form	none	Women consumers - Screener	Attachment 6 - Consumer Screening Instrument rev 6.2.10.doc	No	No	Paper Only

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: 1,948	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	1,948	0	0	0	0	0
Annual IC Time Burden (Hours)	472	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment 1 - Legislative authority	Attachment 1.pdf	07/12/2010
Attachment 8 - Recruitment firm letter	Attachment 8 - Letter from recruitment firm.pdf	07/12/2010
Attachment 12 - Consumer email	Attachment 12 - Consumer Confirmation Email.doc	07/12/2010
Attachment 13 - Couples letter	Attachment 13 - Couples Confirmation Letter_6.24.10.doc	07/12/2010
Attachment 14 - Innovator email	Attachment 14 - Innovator Confirmation Email.doc	07/12/2010
Attachment 15 - Consumer IRB approval	Attachment 15 - IRB Approval Notice (consumer FGs and stakeholder interviews).Full.pdf	07/12/2010
Attachment 16 - Couples IRB approval	Attachment 16 - IRB Approval Notice (couple interviews).pdf	07/12/2010
Supporting statement	Projects 1 & 2 OMB ap Section A_rev 06.24.10.doc	07/12/2010
Literature - recruitment	Pappas-Deluca et al.pdf	07/12/2010
Literature - incentives	Preloran et al.pdf	07/12/2010

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

Formative Research with Consumers, Couples, and Innovators about Reproductive Life Planning and Preconception Health

Health Marketing

OMB: 0920-0798

IC ID: 193776

View Information Collection (IC)