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Skin Cancer Messages among Racial Ethnic Groups at Risk for Delayed Diagnosis, Advanced Disease and Lower Survival
CDC and ATSDR Health Message Testing System
OMB: 0920-0572
IC ID: 226499
OMB.report
HHS/CDC
OMB 0920-0572
ICR 201502-0920-001
IC 226499
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0572 can be found here:
2024-10-18 - Revision of a currently approved collection
2021-08-31 - Extension without change of a currently approved collection
Documents and Forms
Document Name
Document Type
Skin Cancer Messages among Racial Ethnic Groups at Risk for Delayed Diagnosis, Advanced Disease and Lower Survival
Form and Instruction
Screener
ATTACHMENT A1 Screener_04 24 17.docx
Form and Instruction
Informed Consent and Rescreening Form
ATTACHMENT A2 Rescreener and Consent form_04 24 17_0248pm.docx
Form and Instruction
Focus Group Discussion Guide for African American Women
ATTACHMENT B1 FG Guide African American Women 04 24 17.docx
Form and Instruction
Focus Group Discussion Guide for Hispanic Women
ATTACHMENT B2 FG Guide Hispanic Women 04 24 17.docx
Form and Instruction
Focus Group Discussion Guide for African American Men
ATTACHMENT B3 FG Guide African American Male 04 24 17.docx
Form and Instruction
Focus Group Discussion Guide for Hispanic Men
ATTACHMENT B4 FG Guide Hispanic Men 04 24 17.docx
Form and Instruction
Digital Ad Response Sheet (completed during focus groups
ATTACHMENT B5 Digital Ad Response Sheet _ 04 25_17.docx
Form and Instruction
ATTACHMENT C Materials for testing_04 24 17.docx
Materials for Testing
IC Document
HMTS_Expedited_Review_Form_nbl_Revised_4_26_17_5pm.docx
HMTS Review Form for Focus Group Testing of Skin Cancer Messages
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Skin Cancer Messages among Racial Ethnic Groups at Risk for Delayed Diagnosis, Advanced Disease and Lower Survival
Agency IC Tracking Number:
0920-17YM
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
N/A
Screener
ATTACHMENT A1 Screener_04 24 17.docx
No
Paper Only
Form and Instruction
N/A
Informed Consent and Rescreening Form
ATTACHMENT A2 Rescreener and Consent form_04 24 17_0248pm.docx
No
Paper Only
Form and Instruction
N/A
Focus Group Discussion Guide for African American Women
ATTACHMENT B1 FG Guide African American Women 04 24 17.docx
No
Paper Only
Form and Instruction
N/A
Focus Group Discussion Guide for Hispanic Women
ATTACHMENT B2 FG Guide Hispanic Women 04 24 17.docx
No
Paper Only
Form and Instruction
N/A
Focus Group Discussion Guide for African American Men
ATTACHMENT B3 FG Guide African American Male 04 24 17.docx
No
Paper Only
Form and Instruction
N/A
Focus Group Discussion Guide for Hispanic Men
ATTACHMENT B4 FG Guide Hispanic Men 04 24 17.docx
No
Paper Only
Form and Instruction
N/A
Digital Ad Response Sheet (completed during focus groups with men)
ATTACHMENT B5 Digital Ad Response Sheet _ 04 25_17.docx
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Illness Prevention
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
756
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
756
0
756
0
0
0
Annual IC Time Burden (Hours)
398
0
398
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Materials for Testing
ATTACHMENT C Materials for testing_04 24 17.docx
04/24/2017
HMTS Review Form for Focus Group Testing of Skin Cancer Messages
HMTS_Expedited_Review_Form_nbl_Revised_4_26_17_5pm.docx
04/25/2017
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.