Information Collection

Scott County Indiana Public Service Announcements

IC 219996 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⚠️ Notice: This information collection may be referencing outdated material.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 Scott County Indiana Public Service Announcements	Form and Instruction
Focus Group Protoc Focus Group Protocol 2016_2_2_ Indiana PSA Evaluation_Attachment A.docx	Form and Instruction
Screener Screener 2016_2_2_Indiana PSA Evaluation_ Attachment C.docx	Form and Instruction
Facilitator Guide Facilitator Guide 2016_2_2_Indiana PSA Evaluation_Attachment D.docx	Form and Instruction
2016_2_2_Indiana PSA Evaluation_Attachment B.docx Consent Form	IC Document

IC Title:

Scott County Indiana Public Service Announcements

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	Focus Group Protocol	Focus Group Protocol	2016_2_2_ Indiana PSA Evaluation_Attachment A.docx	Yes	Yes	Fillable Printable
Form and Instruction	Screener	Screener	2016_2_2_Indiana PSA Evaluation_ Attachment C.docx	Yes	Yes	Fillable Printable
Form and Instruction	Facilitator Guide	Facilitator Guide	2016_2_2_Indiana PSA Evaluation_Attachment D.docx	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	40	40
Annual IC Time Burden (Hours)	51	51
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Consent Form	2016_2_2_Indiana PSA Evaluation_Attachment B.docx	02/04/2016

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