Web Survey: Fact Sheet, Factsheet Testing Screenshots, Video Testing, and Testing Screenshots

Communications Research for the Development of Messages and Materials about Cytomegalovirus (CMV)

Documents and Forms

Document Name Document Type
Web Survey: Fact Sheet, Factsheet Testing Screenshots, Video Testing, and Testing Screenshots Form and Instruction
Web Survey Attachment 3E Web Survey Screener Screenshots Rev 9 5.docx Form and Instruction
Web Survey Factsheet Attachment 3G Web Survey Factsheet Testing Screenshots Rev 9 5.docx Form and Instruction
Web Survey Video Attachment 3I Web Survey Video Testing Screenshots Rev 9 5.docx Form and Instruction
Attachment 3F Web Survey_Factsheet Testing (rev08272012).docx Attachment 3F Web Survey_Factsheet Testing (rev08272012) IC Document
Attachment 3H Web Survey_Video Testing (rev 08272012).docx Attachment 3H Web Survey_Video Testing (rev 08272012) IC Document

Information Collection (IC) Details

IC Title:	Web Survey: Fact Sheet, Factsheet Testing Screenshots, Video Testing, and Testing Screenshots	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	none	Web Survey Factsheet	Attachment 3G Web Survey Factsheet Testing Screenshots Rev 9 5.docx	No	Paper Only
Form and Instruction	none	Web Survey Video	Attachment 3I Web Survey Video Testing Screenshots Rev 9 5.docx	No	Paper Only
Form and Instruction	none	Web Survey	Attachment 3E Web Survey Screener Screenshots Rev 9 5.docx	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 800	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	800	800
Annual IC Time Burden (Hours)	147	147
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment 3F Web Survey_Factsheet Testing (rev08272012)	Attachment 3F Web Survey_Factsheet Testing (rev08272012).docx	09/07/2012
Attachment 3H Web Survey_Video Testing (rev 08272012)	Attachment 3H Web Survey_Video Testing (rev 08272012).docx	09/07/2012

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