Asthma Control Communication Materials Field Testing (NCEH)

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⚠️ Notice: This information collection may be referencing outdated material.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
Asthma Control Communication Materials Field Testing (NCEH) Form and Instruction
Attachment 2_Focus Group Discussion Guide.docx Other-Discussion Guide
Foduc Group Screener Attachment 1_Focus Group Screener.docx Form and Instruction
Youth Rating Worksheet Attachment 3_Focus Group Rating Worksheet_Youth.docx Form and Instruction
Caregiver Rating Worksheet Attachment 4_Focus Group Rating Worksheet_Caregiver.docx Form and Instruction
Youth Comparison Worksheet Attachment 5_Focus Group Comparison Worksheet_Youth.docx Form and Instruction
Caregiver Comparison Worksheet Attachment 6_Focus Group Comparison Worksheet_Caregiver.docx Form and Instruction
HMTSExpeditedReviewForm_Asthma Control Communication Materials Field Testing.pdf HTMS Review Form IC Document
PrjctDscrptn_Asthma Control Communication Materials Field Testing.docx Project Description IC Document
Attachment 8_Focus Group Youth Assent Form.docx Youth Assent IC Document
Attachment 7_Focus Group Caregiver for Youth Permission Form.docx Caregiver Permission for Youth IC Document
Attachment 9_Focus Group Caregiver Consent Form.docx Caregiver Consent IC Document
Attachment 10_Focus Group Confirmation Email.docx Fogus Group Confirmation Email IC Document
Attachment 11_Focus Group Reminder Email.docx Focus Group Reminder Email IC Document
Attachment 12_Focus Group Message Stimuli.pptx Focus Group Message Stimuli IC Document
List of Attachments.docx List of Attachments IC Document

Information Collection (IC) Details

IC Title:	Asthma Control Communication Materials Field Testing (NCEH)	Agency IC Tracking Number:	0920-0572-18QD

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 and Instruction	none	Foduc Group Screener	Attachment 1_Focus Group Screener.docx	Yes	No	Paper Only
Other-Discussion Guide			Attachment 2_Focus Group Discussion Guide.docx	Yes	No	Paper Only
Form and Instruction	none	Youth Rating Worksheet	Attachment 3_Focus Group Rating Worksheet_Youth.docx	Yes	No	Paper Only
Form and Instruction	none	Caregiver Rating Worksheet	Attachment 4_Focus Group Rating Worksheet_Caregiver.docx	Yes	No	Paper Only
Form and Instruction	none	Youth Comparison Worksheet	Attachment 5_Focus Group Comparison Worksheet_Youth.docx	Yes	No	Paper Only
Form and Instruction	none	Caregiver Comparison Worksheet	Attachment 6_Focus Group Comparison Worksheet_Caregiver.docx	Yes	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 448	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	448	448
Annual IC Time Burden (Hours)	128	128
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
HTMS Review Form	HMTSExpeditedReviewForm_Asthma Control Communication Materials Field Testing.pdf	02/20/2018
Project Description	PrjctDscrptn_Asthma Control Communication Materials Field Testing.docx	02/20/2018
Youth Assent	Attachment 8_Focus Group Youth Assent Form.docx	02/20/2018
Caregiver Permission for Youth	Attachment 7_Focus Group Caregiver for Youth Permission Form.docx	02/20/2018
Caregiver Consent	Attachment 9_Focus Group Caregiver Consent Form.docx	02/20/2018
Fogus Group Confirmation Email	Attachment 10_Focus Group Confirmation Email.docx	02/20/2018
Focus Group Reminder Email	Attachment 11_Focus Group Reminder Email.docx	02/20/2018
Focus Group Message Stimuli	Attachment 12_Focus Group Message Stimuli.pptx	02/20/2018
List of Attachments	List of Attachments.docx	02/20/2018

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