Sub-study #7_Development of Consensus Measures of Distress for the Grid Enabled Measures-Distress Measurement (GEM-DM) Workspace

Questionnaire Cognitive Interviewing and Pretesting (NCI)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0589 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Sub-study #7_Development of Consensus Measures of Distress for the Grid Enabled Measures-Distress Measurement (GEM-DM) Workspace Form and Instruction
1 GEM-DM Survey Attachment A_GEM-DM Survey 8-27-2013.doc Form and Instruction
Gen IC Form_GEM-DM.doc Gen IC Form_GEM-DM IC Document
miniSSA_GEM-DM_2013 9-12-2013.doc miniSSA_GEM-DM_2013 9-12-2013 IC Document
miniSSB_GEM-DM_9_12_13.docx miniSSB_GEM-DM_9_12_13 IC Document
Attachment B_Email Invite 8-6-2013.doc Attachment B_Email Invite 8-6-2013 IC Document
Attachment C_OHSR Exempt.pdf Attachment C_OHSR Exempt IC Document
Attachment D_Measure info.doc Attachment D_Measure info IC Document

Information Collection (IC) Details

IC Title:	Sub-study #7_Development of Consensus Measures of Distress for the Grid Enabled Measures-Distress Measurement (GEM-DM) Workspace	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	GEM-DM Survey	Attachment A_GEM-DM Survey 8-27-2013.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title: "Records of Participants in Programs and Respondents in Surveys Used to Evaluate Programs of the Public Health Service, HHS/PHS/NIH/OD"	FR Citation: 67 FR 60743

Number of Respondents: 100	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	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	100	0	0	0	0	0
Annual IC Time Burden (Hours)	25	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Gen IC Form_GEM-DM	Gen IC Form_GEM-DM.doc	09/12/2013
miniSSA_GEM-DM_2013 9-12-2013	miniSSA_GEM-DM_2013 9-12-2013.doc	09/12/2013
miniSSB_GEM-DM_9_12_13	miniSSB_GEM-DM_9_12_13.docx	09/12/2013
Attachment B_Email Invite 8-6-2013	Attachment B_Email Invite 8-6-2013.doc	09/12/2013
Attachment C_OHSR Exempt	Attachment C_OHSR Exempt.pdf	09/12/2013
Attachment D_Measure info	Attachment D_Measure info.doc	09/12/2013

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