Health and Media Survey

Community Transformation Grants: Evaluation of Nutrition, Physical Activity, and Obesity-related Television Media Campaigns

Documents and Forms

Document Name Document Type
Health and Media Survey Form and Instruction
Attachment 6a Health and Media Survey Attachment 6a_Health and Media Survey_022613.docx Form and Instruction
Attachment 6b Health and Media Survey Attachment 6b (rev) Health and Media Survey Screenshots.pdf Form and Instruction
Attachment 8_Email Notification and Reminders.docx Attachment 8_Email Notification and Reminders IC Document

Information Collection (IC) Details

IC Title:	Health and Media Survey	Agency IC Tracking Number:

Is this a Common Form? No		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	Attachment 6a Health and Media Survey	Attachment 6a_Health and Media Survey_022613.docx		Yes	Yes	Fillable Fileable
Form and Instruction	None	Attachment 6b Health and Media Survey	Attachment 6b (rev) Health and Media Survey Screenshots.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 15,399	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	15,399	15,399
Annual IC Time Burden (Hours)	7,700	7,700
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment 8_Email Notification and Reminders	Attachment 8_Email Notification and Reminders.docx	10/29/2012

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