Information Collection

Focus Groups on proposed materials for a pediatric palliative care communications campaign

IC 202422 under ICR 201202-0925-003 · OMB 0925-0653.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0653 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Focus Groups on proposed materials for a pediatric palliative care communications campaign	Form and Instruction
1 Focus Group Screener and Consent Appendix B_Screenshots Focus Group Screener and consent.pdf	Form and Instruction
2 Focus Group Moderator Guide Appendix C_Focus Group Moderator Guide.doc	Form and Instruction
3 Focus Group Screenshots Appendix D_Screenshots Focus Group.pdf	Form and Instruction
Form for Generic Fast Track Clearance_Focus Groups FINAL.DOC Form for Generic Fast Track Clearance_Focus Groups FINAL	IC Document
Appendix E_Materials_Storyboards video module 1.pdf Appendix E_Materials_Storyboards video module 1	IC Document
Appendix E_Materials_Storyboards video module 2.pdf Appendix E_Materials_Storyboards video module 2	IC Document
Appendix E_Materials_Interactive Worksheet.pdf Appendix E_Materials_Interactive Worksheet	IC Document
Appendix E_Materials_Logo options.pdf Appendix E_Materials_Logo options	IC Document
Appendix E_Materials_Video description and scripts.doc Appendix E_Materials_Video description and scripts	IC Document
Appendix F_Correspondence.doc Appendix F_Correspondence	IC Document
Appendix A_ Focus Group Screener and consent.doc Appendix A_ Focus Group Screener and consent	IC Document

IC Title:

Focus Groups on proposed materials for a pediatric palliative care communications campaign

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	1	Focus Group Screener and Consent	Appendix B_Screenshots Focus Group Screener and consent.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	2	Focus Group Moderator Guide	Appendix C_Focus Group Moderator Guide.doc	Yes	Yes	Fillable Fileable
Form and Instruction	3	Focus Group Screenshots	Appendix D_Screenshots Focus Group.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 69

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

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	69	0	0	0	0	0
Annual IC Time Burden (Hours)	44	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
Form for Generic Fast Track Clearance_Focus Groups FINAL	Form for Generic Fast Track Clearance_Focus Groups FINAL.DOC	05/23/2012
Appendix E_Materials_Storyboards video module 1	Appendix E_Materials_Storyboards video module 1.pdf	05/23/2012
Appendix E_Materials_Storyboards video module 2	Appendix E_Materials_Storyboards video module 2.pdf	05/23/2012
Appendix E_Materials_Interactive Worksheet	Appendix E_Materials_Interactive Worksheet.pdf	05/23/2012
Appendix E_Materials_Logo options	Appendix E_Materials_Logo options.pdf	05/23/2012
Appendix E_Materials_Video description and scripts	Appendix E_Materials_Video description and scripts.doc	05/23/2012
Appendix F_Correspondence	Appendix F_Correspondence.doc	05/23/2012
Appendix A_ Focus Group Screener and consent	Appendix A_ Focus Group Screener and consent.doc	05/23/2012

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