Information Collection

Bundled sub-studies #17 (CIS) and #18 (Message)

IC 198803 under ICR 201008-0925-004 · OMB 0925-0046.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0046 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Bundled sub-studies #17 (CIS) and #18 (Message)	Form and Instruction
1 #17 Email Form and Survey #17_Attach 17C Email Form and 17D Survey_CIS.docx	Form and Instruction
2 #18 Moderator's Guide and Screener #18_Attach 18B guide & 18C Screener.docx	Form and Instruction
Memo to OMB_Key To Bundle #17 & 18.doc Memo to OMB_Key To Bundle #17 & 18	IC Document
#17 and #18_Gen Sub-Study Form_CIS and Message.doc #17 and #18_Gen Sub-Study Form_CIS and Message	IC Document
#17_Justif memo & Attach 17A and17 B_CIS_7-27-2011.docx #17_Justif memo & Attach 17A and17 B_CIS_7-27-2011	IC Document
#18_Justif Memo & Attach 18A Themes 18D Consent_Message.doc #18_Justif Memo & Attach 18A Themes 18D Consent_Message	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Bundled sub-studies #17 (CIS) and #18 (Message)

Agency IC Tracking Number:

IC Status: New

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	#17 Email Form and Survey	#17_Attach 17C Email Form and 17D Survey_CIS.docx		Yes	Yes	Fillable Fileable
Form and Instruction	2	#18 Moderator's Guide and Screener	#18_Attach 18B guide & 18C Screener.docx		Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: SORN #09-25-0156, "Records of Participants in Programs and Respondents in Surveys Used to Evaluate Programs of the Public Health Service, HHS/PHS/NIH/OD"

FR Citation: 67 FR 60743

Number of Respondents: 335

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 60 %

table that charts list of burden
	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	335	0	0	0	0	0
Annual IC Time Burden (Hours)	156	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Memo to OMB_Key To Bundle #17 & 18	Memo to OMB_Key To Bundle #17 & 18.doc	07/27/2011
#17 and #18_Gen Sub-Study Form_CIS and Message	#17 and #18_Gen Sub-Study Form_CIS and Message.doc	07/27/2011
#17_Justif memo & Attach 17A and17 B_CIS_7-27-2011	#17_Justif memo & Attach 17A and17 B_CIS_7-27-2011.docx	07/27/2011
#18_Justif Memo & Attach 18A Themes 18D Consent_Message	#18_Justif Memo & Attach 18A Themes 18D Consent_Message.doc	07/27/2011

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