Information Collection

Video Concept Pretesting

IC 192428 under ICR 201005-0925-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

IC Title:

Video Concept Pretesting

Agency IC Tracking Number:

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of 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 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	400	400
Annual IC Time Burden (Hours)	117	117
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.