Information Collection

Message Testing for CDCs Division of Community Health with the General Public, Engaged Public, and Community Leaders

IC 204153 under ICR 201111-0920-003 · OMB 0920-0572.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0572 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0572 Message Testing for CDCs Division of Community Health with the General Public, Engaged Public, and Community Leaders	Form and Instruction
DCH Screener- General Public FG Engaged Public Triad.docx	Instruction
Consent form- Community Leaders Triad.docx	Instruction
Consent form- Engaged Public Triad.docx	Instruction
Consent form- General Public FG.docx	Instruction
0920-0572 Moderators Guide- Engaged Public Triad Moderators Guide- Engaged Public Triad.docx	Form and Instruction
0920-0572 Moderators Guide- Community Leaders Triad Moderators Guide- Community Leaders Triad.docx	Form and Instruction
0920-0572 Moderators Guide- General Public FG Moderators Guide- General Public FG.docx	Form and Instruction
DCH Message Testing Supplement.docx DCH Message Testing Supplement	IC Document
Burden table by audience and activity.docx Burden table by audience and activity	IC Document
Overview of Recruitment Process for Community Leaders.docx Overview of Recruitment Process for Community Leaders	IC Document
HMTS Expedited Review Form 090412.pdf HMTS Expedited Review Form 090412	IC Document

IC Title:

Message Testing for CDCs Division of Community Health with the General Public, Engaged Public, and Community Leaders

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-0572	Moderators Guide- Community Leaders Triad	Moderators Guide- Community Leaders Triad.docx	Yes	Yes	Printable Only
Form and Instruction	0920-0572	Moderators Guide- General Public FG	Moderators Guide- General Public FG.docx	Yes	Yes	Fillable Printable
Instruction			Consent form- Community Leaders Triad.docx	Yes	Yes	Printable Only
Instruction			Consent form- Engaged Public Triad.docx	Yes	Yes	Printable Only
Instruction			Consent form- General Public FG.docx	Yes	Yes	Printable Only
Form and Instruction	0920-0572	Moderators Guide- Engaged Public Triad	Moderators Guide- Engaged Public Triad.docx	Yes	Yes	Fillable Printable
Instruction			DCH Screener- General Public FG Engaged Public Triad.docx	Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 336

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

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	336	0	0	0	0	0
Annual IC Time Burden (Hours)	492	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
DCH Message Testing Supplement	DCH Message Testing Supplement.docx	09/14/2012
Burden table by audience and activity	Burden table by audience and activity.docx	09/14/2012
Overview of Recruitment Process for Community Leaders	Overview of Recruitment Process for Community Leaders.docx	09/14/2012
HMTS Expedited Review Form 090412	HMTS Expedited Review Form 090412.pdf	09/18/2012

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