Assessing the Effectiveness of HEADS UP Message

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1009 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-1009 Assessing the Effectiveness of HEADS UP Message Form and Instruction
0920-1009 Attachment A_Screener Attachment A_Screener.docx Form and Instruction
0920-1009 Attachment B_Instrument Attachment B_Instrument.docx Form and Instruction
Attachment D_Informed Consent.docx Attachment C_Survey Screenshots IC Document
Attachment D_Informed Consent.docx Attachment D_Informed Consent IC Document
GenIC Request_Improving TBI Message_ICRO.docx GenIC Request_Improving TBI Message_ IC Document

Information Collection (IC) Details

IC Title:	Assessing the Effectiveness of HEADS UP Message	Agency IC Tracking Number:	16ABH

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	0920-1009	Attachment A_Screener	Attachment A_Screener.docx		Yes	Yes	Fillable Printable
Form and Instruction	0920-1009	Attachment B_Instrument	Attachment B_Instrument.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 400	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	400	400
Annual IC Time Burden (Hours)	40	40
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment C_Survey Screenshots	Attachment D_Informed Consent.docx	04/19/2016
Attachment D_Informed Consent	Attachment D_Informed Consent.docx	04/19/2016
GenIC Request_Improving TBI Message_	GenIC Request_Improving TBI Message_ICRO.docx	04/19/2016

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