Information Collection

Audience Research on Self-Management Education, Phase III

IC 213762 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⚠️ Notice: This information collection may be referencing outdated material.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 Audience Research on Self-Management Education, Phase III	Form and Instruction
0920-0572 Attachment 4 Screener_10282014 Attachment 4 Screener_10282014.docx	Form and Instruction
0920-0572 Attachment 3 Mod Guide_10282014 Attachment 3 Mod Guide_10282014.docx	Form and Instruction
Attachment 1 Research Plan and Burden_10282014.docx Attachment 1 Research Plan and Burden_10282014	IC Document
Attachment 2 Materials_v3 10282014.docx Attachment 2 Materials_v3 10282014	IC Document
Attachment 5 Consent_10 27.docx Attachment 5 Consent_10 27	IC Document
HMTS Expedited Review Form_SME 10282014 V3.docx HMTS Expedited Review Form_SME 10282014 V3	IC Document

IC Title:

Audience Research on Self-Management Education, Phase III

Agency IC Tracking Number:

0920-15DC

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	0920-0572	Attachment 4 Screener_10282014	Attachment 4 Screener_10282014.docx		Yes	Yes	Fillable Printable
Form and Instruction	0920-0572	Attachment 3 Mod Guide_10282014	Attachment 3 Mod Guide_10282014.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 160

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 Agency Discretion
Annual Number of Responses for this IC	160	160
Annual IC Time Burden (Hours)	134	134
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 1 Research Plan and Burden_10282014	Attachment 1 Research Plan and Burden_10282014.docx	11/10/2014
Attachment 2 Materials_v3 10282014	Attachment 2 Materials_v3 10282014.docx	11/10/2014
Attachment 5 Consent_10 27	Attachment 5 Consent_10 27.docx	11/10/2014
HMTS Expedited Review Form_SME 10282014 V3	HMTS Expedited Review Form_SME 10282014 V3.docx	11/10/2014

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