Information Collection

Talk - Focus Group

IC 219214 under ICR 201306-0930-003 · OMB 0930-0196.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0196 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Focus Group Protoc Talk - Focus Group	Form and Instruction
Focus Group Protoc Focus Group Protocol Attachment A-Focus Group Protocol 12.7.15.docx	Form and Instruction
Screener Screener Attachment B-Screening 12.7.15.docx	Form and Instruction
Attachment C-Consent Form 12.7.15.docx Consent Form	IC Document
Attachment D-Facilitator Guide 12.7.15.docx Facilitator Guide	IC Document
SS-12.8.15.docx Supporting Statement	IC Document
TransLet-4doc.doc Transmittal Letter	IC Document
SS-12.8.15.docx Supporting Statement	IC Document

IC Title:

Talk - Focus Group

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Focus Group Protocol	Focus Group Protocol	Attachment A-Focus Group Protocol 12.7.15.docx		Yes	Yes	Fillable Fileable
Form and Instruction	Screener	Screener	Attachment B-Screening 12.7.15.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 180

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	180	180
Annual IC Time Burden (Hours)	90	90
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Consent Form	Attachment C-Consent Form 12.7.15.docx	12/08/2015
Facilitator Guide	Attachment D-Facilitator Guide 12.7.15.docx	12/08/2015
Supporting Statement	SS-12.8.15.docx	12/08/2015
Transmittal Letter	TransLet-4doc.doc	12/08/2015
Supporting Statement	SS-12.8.15.docx	12/08/2015

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