Information Collection

Video Concept Pretesting

IC 192428 under ICR 200901-0925-005 · OMB 0925-0585.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0585 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Video Concept Pretesting Form and Instruction
1 video Appendix 1 Online Survey Instrument Revised 10-0329.doc Form and Instruction
Appendix 4 IRB Exemption Review.doc Appendix 4 IRB Exemption Review IC Document
Appendix 3 Notification of Privacy Act.doc Appendix 3 Notification of Privacy Act IC Document
Appendix 2 AED Guidelines for Data Security.doc Appendix 2 AED Guidelines for Data Security IC Document
Generic Clearance Form 0925-0585-05.DOCX Generic Clearance Form 0925-0585-05 IC Document
Mini Supporting Statement 0925-0585-05.docx Mini Supporting Statement 0925-0585-05 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Video Concept Pretesting	Agency IC Tracking Number:

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	1	video	Appendix 1 Online Survey Instrument Revised 10-0329.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

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: 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	400	0	0	0	0	0
Annual IC Time Burden (Hours)	117	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Appendix 4 IRB Exemption Review	Appendix 4 IRB Exemption Review.doc	03/29/2010
Appendix 3 Notification of Privacy Act	Appendix 3 Notification of Privacy Act.doc	03/29/2010
Appendix 2 AED Guidelines for Data Security	Appendix 2 AED Guidelines for Data Security.doc	03/29/2010
Generic Clearance Form 0925-0585-05	Generic Clearance Form 0925-0585-05.DOCX	03/29/2010
Mini Supporting Statement 0925-0585-05	Mini Supporting Statement 0925-0585-05.docx	03/29/2010

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