Information Collection

Formative Research to Develop Social Marketing Campaigns: Prevention Is Care (PIC)

IC 213098 under ICR 201301-0920-010 · OMB 0920-0840.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0840 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Formative Research to Develop Social Marketing Campaigns: Prevention Is Care (PIC)	Form
Provider Screening Instrument Att 4 Provider Screening Instrument.docx	Form and Instruction
Paper and Pencil Survey Att 2 Paper and Pencil Survey.docx	Form
Informed Consent Form Att 6 Informed Consent Forms.docx	Form
Provider Screening Instrument Att 3 Provider Interview Guide.docx	Form and Instruction
Review Material-Envelope Att 5.1_Envelope.pdf	Form
Review Material Folder Att 5.2_Folder.pdf	Form
Review Material Brouchure and Folding Instructions Att 5.3_BRC & folding instructions.pdf	Form
Review Material Patient Baseline Screen Att 5.4_Patient Baseline Screener.pdf	Form
Review Material Patient Adherence Brochure Att 5.5_Patient Adherence Brochure.pdf	Form
Review Material Adherence Wall Poster Att 5.6_Adherence Wall Poster.pdf	Form
Review Material Risk Reduction MD Brochure Att 5.7_Risk Reduct MD Brochure.pdf	Form
Review Material Patient Action Plan Att 5.8_Patient Action Plan.pdf	Form
Review Material Patient Risk Reduction Brochure Att 5.9_Patient Risk Reduct Brochure.pdf	Form
Review Material Retention Brochure MD Att 5.10_Retent MD Brochure.pdf	Form
Review Material Patient Record Form Att 5.11_Patient Record Form.pdf	Form
Review Material Retention Brochure Patient Att 5.12_Patient Retent Brochure.pdf	Form
Review Material Retention Poster Att 5.13_Retent_Poster.pdf	Form
Review Material Gardner Study Reprint Att 5.14_Gardner Reprint Carrier.pdf	Form
Review Material Adherence Brochure MD Att 5.15_Adherence MD Brochure.pdf	Form
CME Promotion Card Att 5.16_CME Promo Card.pdf	Form
Review Material Risk Reduction Poster Option Att 5.17_Risk Reduct Poster Option.pdf	Form
Att 7 IRB Approval.pdf IRB Approval Letter	IC Document
Att 8 Reminder Email_Letter.docx Reminder Email Letter	IC Document
SSB 02SEP2014.docx Supporting Statement B	IC Document
Att 1 Privacy Agreement.docx Privacy Agreement	IC Document
SSA 07OCT14.doc Supporting Statement A	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Formative Research to Develop Social Marketing Campaigns: Prevention Is Care (PIC)

Agency IC Tracking Number:

0920-0840-14AXK

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?	Electronic Capability
Form	None	Review Material Patient Adherence Brochure	Att 5.5_Patient Adherence Brochure.pdf	None	No	Paper Only
Form	None	Review Material Adherence Wall Poster	Att 5.6_Adherence Wall Poster.pdf	None	No	Paper Only
Form	None	Review Material Risk Reduction MD Brochure	Att 5.7_Risk Reduct MD Brochure.pdf	None	No	Paper Only
Form	None	Review Material Patient Action Plan	Att 5.8_Patient Action Plan.pdf	None	No	Paper Only
Form	None	Review Material Patient Risk Reduction Brochure	Att 5.9_Patient Risk Reduct Brochure.pdf		No	Paper Only
Form	None	Review Material Retention Brochure MD	Att 5.10_Retent MD Brochure.pdf	None	No	Paper Only
Form	None	Review Material Patient Record Form	Att 5.11_Patient Record Form.pdf	None	No	Paper Only
Form	None	Review Material Retention Brochure Patient	Att 5.12_Patient Retent Brochure.pdf	None	No	Paper Only
Form	None	Review Material Retention Poster	Att 5.13_Retent_Poster.pdf	None	No	Paper Only
Form	None	Review Material Gardner Study Reprint	Att 5.14_Gardner Reprint Carrier.pdf	None	No	Paper Only
Form	None	Review Material Adherence Brochure MD	Att 5.15_Adherence MD Brochure.pdf	None	No	Paper Only
Form	None	CME Promotion Card	Att 5.16_CME Promo Card.pdf	None	No	Paper Only
Form	None	Review Material Risk Reduction Poster Option	Att 5.17_Risk Reduct Poster Option.pdf	None	No	Paper Only
Form and Instruction	None	Provider Screening Instrument	Att 4 Provider Screening Instrument.docx	None	No	Paper Only
Form	None	Paper and Pencil Survey	Att 2 Paper and Pencil Survey.docx	None	No	Paper Only
Form	None	Informed Consent Form	Att 6 Informed Consent Forms.docx	None	No	Paper Only
Form and Instruction	None	Provider Screening Instrument	Att 3 Provider Interview Guide.docx	None	No	Paper Only
Form	None	Review Material-Envelope	Att 5.1_Envelope.pdf	None	No	Paper Only
Form	None	Review Material Folder	Att 5.2_Folder.pdf	None	No	Paper Only
Form	None	Review Material Brouchure and Folding Instructions	Att 5.3_BRC & folding instructions.pdf	None	No	Paper Only
Form	None	Review Material Patient Baseline Screen	Att 5.4_Patient Baseline Screener.pdf	None	No	Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 480

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	480	480
Annual IC Time Burden (Hours)	154	154
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
IRB Approval Letter	Att 7 IRB Approval.pdf	09/24/2014
Reminder Email Letter	Att 8 Reminder Email_Letter.docx	09/24/2014
Supporting Statement B	SSB 02SEP2014.docx	09/24/2014
Privacy Agreement	Att 1 Privacy Agreement.docx	09/24/2014
Supporting Statement A	SSA 07OCT14.doc	10/07/2014

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