Information Collection

Open Call Usability Testing (NCI)

IC 217694 under ICR 201304-0925-003 · OMB 0925-0046.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0046 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Open Call Usability Testing (NCI)	Form and Instruction
1 Attachment 1 Screener Lay Consumers English Attachment 1 Screener Lay Consumers_English.doc	Form and Instruction
2 Attachment 3 Screener Lay Consumers Spanish Attachment 3 Screener Lay Consumers_Spanish.doc	Form and Instruction
3 Attadchment 2 Screener Healthcare Professionals English Attachment 2 Screener Healthcare Professionals_English.doc	Form and Instruction
4 Attachment 4 Screener Healthcare Professionals Spanish Attachment 4 Screener Healthcare Professionals_Spanish.doc	Form and Instruction
5 Attachment 7 Informed Consent Form English Attachment 7 Informed Consent Form (English).doc	Form and Instruction
6 Attachment 8 Informed Consent Form Spanish Attachment 8 Informed Consent Form (Spanish).doc	Form and Instruction
7 Attachment 5 Usability Testing Attachment 5 Moderator Guide_English.doc	Form and Instruction
8 Attachment 6 Usability Testing Spanish Attachment 6 Moderator Guide_Spanish.doc	Form and Instruction
Attachment 9 IRB Approval.pdf Attachment 9 IRB Approval	IC Document
Open Call OMB SSA submission_FINAL 8.13.2015.docx Open Call OMB SSA submission	IC Document

IC Title:

Open Call Usability Testing (NCI)

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	Attachment 1 Screener Lay Consumers English	Attachment 1 Screener Lay Consumers_English.doc	Yes	Yes	Fillable Fileable
Form and Instruction	2	Attachment 3 Screener Lay Consumers Spanish	Attachment 3 Screener Lay Consumers_Spanish.doc	Yes	Yes	Fillable Fileable
Form and Instruction	3	Attadchment 2 Screener Healthcare Professionals English	Attachment 2 Screener Healthcare Professionals_English.doc	Yes	Yes	Fillable Fileable
Form and Instruction	4	Attachment 4 Screener Healthcare Professionals Spanish	Attachment 4 Screener Healthcare Professionals_Spanish.doc	Yes	Yes	Fillable Fileable
Form and Instruction	5	Attachment 7 Informed Consent Form English	Attachment 7 Informed Consent Form (English).doc	Yes	Yes	Fillable Fileable
Form and Instruction	6	Attachment 8 Informed Consent Form Spanish	Attachment 8 Informed Consent Form (Spanish).doc	Yes	Yes	Fillable Fileable
Form and Instruction	7	Attachment 5 Usability Testing	Attachment 5 Moderator Guide_English.doc	Yes	Yes	Fillable Fileable
Form and Instruction	8	Attachment 6 Usability Testing Spanish	Attachment 6 Moderator Guide_Spanish.doc	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 492

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	492	492
Annual IC Time Burden (Hours)	172	172
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 9 IRB Approval	Attachment 9 IRB Approval.pdf	08/13/2015
Open Call OMB SSA submission	Open Call OMB SSA submission_FINAL 8.13.2015.docx	08/17/2015

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