Document Name Document Type
Form Attachment D Monthly Outcome Survey (MOS) Form and Instruction
ASPA_MonthlyOutcomeSurvey_AQ_Wave11_110521_FINAL.docx Other-MOS Wave11
ASPA_MonthlyOutcomeSurvey_AQ_Wave11_110521_FINAL.docx Other-MOS Wave11
Attachment D Attachment D: COVID-19 Monthly Outcome Survey – Question Part A_Attachment D_COVID-19 Monthly Outcome Survey_Questionnaire.docx Form and Instruction
Attachment D Attachment D: COVID-19 Monthly Outcome Survey – Question Part A_Attachment D_COVID-19 Monthly Outcome Survey_Questionnaire.docx Form and Instruction
Attachment E Attachment E: COVID-19 Monthly Outcome Survey – Ipsos Om Part A_Attachment E_COVID-19 Monthly Outcome Survey_Ipsos Omnibus COVID Questions.docx Form and Instruction
Attachment E Attachment E: COVID-19 Monthly Outcome Survey – Ipsos Om Part A_Attachment E_COVID-19 Monthly Outcome Survey_Ipsos Omnibus COVID Questions.docx Form and Instruction
Attachment F Attachment F: COVID-19 Monthly Outcome Survey – Consent Part A_Attachment F_COVID-19 Monthly Outcome Survey_Ipsos Consent Form.docx Form and Instruction
Attachment F Attachment F: COVID-19 Monthly Outcome Survey – Consent Part A_Attachment F_COVID-19 Monthly Outcome Survey_Ipsos Consent Form.docx Form and Instruction
Attachment G Attachment G: COVID-19 Monthly Outcome Survey – Communic Part A_Attachment G_COVID-19 Monthly Outcome Survey_Communications.docx Form and Instruction
Attachment G Attachment G: COVID-19 Monthly Outcome Survey – Communic Part A_Attachment G_COVID-19 Monthly Outcome Survey_Communications.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Monthly Outcome Survey (MOS)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	Attachment D	Attachment D: COVID-19 Monthly Outcome Survey – Questionnaire	Part A_Attachment D_COVID-19 Monthly Outcome Survey_Questionnaire.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Attachment E	Attachment E: COVID-19 Monthly Outcome Survey – Ipsos Omnibus COVID Questions	Part A_Attachment E_COVID-19 Monthly Outcome Survey_Ipsos Omnibus COVID Questions.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Attachment F	Attachment F: COVID-19 Monthly Outcome Survey – Consent Form	Part A_Attachment F_COVID-19 Monthly Outcome Survey_Ipsos Consent Form.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Attachment G	Attachment G: COVID-19 Monthly Outcome Survey – Communications	Part A_Attachment G_COVID-19 Monthly Outcome Survey_Communications.docx	Yes	Yes	Fillable Fileable
Other-MOS Wave11			ASPA_MonthlyOutcomeSurvey_AQ_Wave11_110521_FINAL.docx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,000	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	Previously Approved
Annual Number of Responses for this IC	120,000	60,000	60,000
Annual IC Time Burden (Hours)	30,000	19,800	10,200
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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

Monthly Outcome Survey (MOS)

ASPA COVID-19 Public Education Campaign Evaluation Surveys

OMB: 0990-0475

IC ID: 245272

View Information Collection (IC)