Audience Research on Self-Management Education

CDC and ATSDR Health Message Testing System

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0572 can be found here:

Documents and Forms

Document Name Document Type
Audience Research on Self-Management Education Form and Instruction
Moderator's Guide Attachment 3 - Moderators Guide 052313.docx Form and Instruction
Screener Attachment 2 - Eligibility Screener 052313.docx Form and Instruction
Attachment 4- Informed Consent Form 052313.docx Consent IC Document
Attachment 5 - Materials 052313.docx Materials IC Document
DPH_HMTS Expedited Review Form 052313.docx Expedited Review Form IC Document
Attachment 1 - Research Plan - Burden Table 052313.docx Supporting Information IC Document
List of Attachments 052313.docx List of Attachments IC Document

Information Collection (IC) Details

IC Title:	Audience Research on Self-Management Education	Agency IC Tracking Number:

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
Form and Instruction	none	Moderator's Guide	Attachment 3 - Moderators Guide 052313.docx		No	No	Printable Only
Form and Instruction	none	Screener	Attachment 2 - Eligibility Screener 052313.docx		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 120	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	120	0	0	0	0	0
Annual IC Time Burden (Hours)	200	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Consent	Attachment 4- Informed Consent Form 052313.docx	05/29/2013
Materials	Attachment 5 - Materials 052313.docx	05/29/2013
Expedited Review Form	DPH_HMTS Expedited Review Form 052313.docx	05/29/2013
Supporting Information	Attachment 1 - Research Plan - Burden Table 052313.docx	05/29/2013
List of Attachments	List of Attachments 052313.docx	05/29/2013

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