Document Name Document Type
African American STD Disparities Health Communications Project and Community Health Media Center Educational Campaign Materials Testing Form
African American Screener African Amer - Attachment 3 - Survey screener 040313.doc Form
African American Survey African Amer - Attachment 4 - Survey 022513.doc Form
Community Health Wave 1 Screener Attachment 2a - Wave 1 Beverages - Screener - 040413.pdf Form
Community Health Wave 2 Screener Attachment 3a - Wave 2 Physical Activity - Screener - 040413.pdf Form
Community Health Wave 3 Screener Attachment 4a - Wave 3 Food - Screener - 040413.pdf Form
Community Health Wave 4 Screener Attachment 5a - Wave 4 Healthy Living - Screener - 040413.pdf Form
Community Health Wave 1 Survey Screenshots Attachment 2c - Wave 1 Beverages - Screenshots - 040413.pdf Form
Community Health Wave 2 Survey Screenshots Attachment 3c - Wave 2 Physical Activity - Screenshots - 040413.pdf Form
Community Health Wave 3 Survey Screenshots Attachment 4c - Wave 3 Food - Screenshots - 040413.pdf Form
Community Health Wave 4 Survey Screenshots Attachment 5c - Wave 4 Healthy Living - Screenshots - 040413.pdf Form
African Amer HMTS Expedited Review Form 022513.pdf African American HTMS Expedited Review Form IC Document
African Amer - Attachment 2 - Survey Invitation and Reminder E-Mails 022513.docx African American Email Invitation and Reminders IC Document
Attachment 11 - IRB Ruling 060308.doc African American IRB Letter IC Document
African Amer -Attachment 1- Consent Form 022513.doc African American Consent IC Document
Community Health - HMTS Expedited Review Form - 040213.pdf Community Health HMTS Expedited Review Form IC Document
Community Health Attachment 1 - TOC - Summary of Procedures - Burden Table - 040213.pdf Community Health Summary of Procedures IC Document
Attachment 2d - Wave 1 Beverages - Materials List - 040413.pdf Community Health Wave 1 Materials IC Document
Attachment 3d - Wave 2 Physical Activity - Materials List - 040413.pdf Community Health Wave 2 Materials IC Document
Attachment 4d - Wave 3 Food - Materials List - 040413.pdf Community Health Wave 3 Materials IC Document
Attachment 5d - Wave 4 Healthy Living - Materials List - 040413.pdf Community Health Wave 4 Materials IC Document
Attachment 2b - Wave 1 Beverages - Survey - 040413.pdf Community Health Wave 1 Survey IC Document
Attachment 3b - Wave 2 Physical Activity - Survey - 040413.pdf Community Health Wave 2 Survey IC Document
Attachment 4b - Wave 3 Food - Survey - 040413.pdf Community Health Wave 3 Survey IC Document
Attachment 5b - Wave 4 Healthy Living - Survey - 040413.pdf Community Health Wave 4 Survey IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	African American STD Disparities Health Communications Project and Community Health Media Center Educational Campaign Materials Testing	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	African American Screener	African Amer - Attachment 3 - Survey screener 040313.doc	Yes	Yes	Fillable Fileable
Form	none	African American Survey	African Amer - Attachment 4 - Survey 022513.doc	Yes	Yes	Fillable Fileable
Form	none	Community Health Wave 1 Screener	Attachment 2a - Wave 1 Beverages - Screener - 040413.pdf	Yes	Yes	Fillable Fileable
Form	none	Community Health Wave 2 Screener	Attachment 3a - Wave 2 Physical Activity - Screener - 040413.pdf	Yes	Yes	Fillable Fileable
Form	none	Community Health Wave 3 Screener	Attachment 4a - Wave 3 Food - Screener - 040413.pdf	Yes	Yes	Fillable Fileable
Form	none	Community Health Wave 4 Screener	Attachment 5a - Wave 4 Healthy Living - Screener - 040413.pdf	Yes	Yes	Fillable Fileable
Form	none	Community Health Wave 1 Survey Screenshots	Attachment 2c - Wave 1 Beverages - Screenshots - 040413.pdf	Yes	Yes	Fillable Fileable
Form	none	Community Health Wave 2 Survey Screenshots	Attachment 3c - Wave 2 Physical Activity - Screenshots - 040413.pdf	Yes	Yes	Fillable Fileable
Form	none	Community Health Wave 3 Survey Screenshots	Attachment 4c - Wave 3 Food - Screenshots - 040413.pdf	Yes	Yes	Fillable Fileable
Form	none	Community Health Wave 4 Survey Screenshots	Attachment 5c - Wave 4 Healthy Living - Screenshots - 040413.pdf	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,950	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	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	5,950	0	0	0	0	0
Annual IC Time Burden (Hours)	2,406	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
African American HTMS Expedited Review Form	African Amer HMTS Expedited Review Form 022513.pdf	04/03/2013
African American Email Invitation and Reminders	African Amer - Attachment 2 - Survey Invitation and Reminder E-Mails 022513.docx	04/03/2013
African American IRB Letter	Attachment 11 - IRB Ruling 060308.doc	04/03/2013
African American Consent	African Amer -Attachment 1- Consent Form 022513.doc	04/04/2013
Community Health HMTS Expedited Review Form	Community Health - HMTS Expedited Review Form - 040213.pdf	04/04/2013
Community Health Summary of Procedures	Community Health Attachment 1 - TOC - Summary of Procedures - Burden Table - 040213.pdf	04/04/2013
Community Health Wave 1 Materials	Attachment 2d - Wave 1 Beverages - Materials List - 040413.pdf	04/08/2013
Community Health Wave 2 Materials	Attachment 3d - Wave 2 Physical Activity - Materials List - 040413.pdf	04/08/2013
Community Health Wave 3 Materials	Attachment 4d - Wave 3 Food - Materials List - 040413.pdf	04/08/2013
Community Health Wave 4 Materials	Attachment 5d - Wave 4 Healthy Living - Materials List - 040413.pdf	04/08/2013
Community Health Wave 1 Survey	Attachment 2b - Wave 1 Beverages - Survey - 040413.pdf	04/08/2013
Community Health Wave 2 Survey	Attachment 3b - Wave 2 Physical Activity - Survey - 040413.pdf	04/08/2013
Community Health Wave 3 Survey	Attachment 4b - Wave 3 Food - Survey - 040413.pdf	04/08/2013
Community Health Wave 4 Survey	Attachment 5b - Wave 4 Healthy Living - Survey - 040413.pdf	04/08/2013

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

African American STD Disparities Health Communications Project and Community Health Media Center Educational Campaign Materials Testing

CDC and ATSDR Health Message Testing System

OMB: 0920-0572

IC ID: 206414

View Information Collection (IC)