Healthy People 2020 Consortium Member Assessment to Support the US DHHS

Prevention Communication Formative Research

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0281 can be found here:

Documents and Forms

Document Name Document Type
Form 0990-0281 Healthy People 2020 Consortium Member Assessment to Support the US DHHS Form
0990-0281 Focus Group and Interview recruitment Screener 0990-0281Focus Group and Interview Screening Instrument 2009-17-09 (2).rtf Form
0990-0281 Interviewer's Guide 0990-0281Interview Guide 2009-17-09 (2).rtf Form
0990-0281 Moderator's Guide 0990-0281Focus Group Guide 2009-17-09 (2).rtf Form
0990-0281 Healthy People 2020 Consortium Member Assessment 0990-0281Healthy People 2020 Consortium Member Assessment 2009-17-09 (2).doc Form
OMB Memo 0990-0281 #2 2009-12-14.doc Statement of Need IC Document
0990-0281OMB Timeline memo.pdf Timeline memo IC Document
HP2020 Consortium Assessment Consent 2010-01-28.docx Consent Form IC Document

Information Collection (IC) Details

IC Title:	Healthy People 2020 Consortium Member Assessment to Support the US DHHS	Agency IC Tracking Number:

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	0990-0281	Moderator's Guide	0990-0281Focus Group Guide 2009-17-09 (2).rtf	Yes	Yes	Printable Only
Form	0990-0281	Healthy People 2020 Consortium Member Assessment	0990-0281Healthy People 2020 Consortium Member Assessment 2009-17-09 (2).doc	Yes	Yes	Printable Only
Form	0990-0281	Focus Group and Interview recruitment Screener	0990-0281Focus Group and Interview Screening Instrument 2009-17-09 (2).rtf	Yes	No	Printable Only
Form	0990-0281	Interviewer's Guide	0990-0281Interview Guide 2009-17-09 (2).rtf	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 168	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	168	0	0	0	0	0
Annual IC Time Burden (Hours)	86	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Statement of Need	OMB Memo 0990-0281 #2 2009-12-14.doc	12/17/2009
Timeline memo	0990-0281OMB Timeline memo.pdf	12/17/2009
Consent Form	HP2020 Consortium Assessment Consent 2010-01-28.docx	02/19/2010

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