Information Collection

Rough Cut Testing of Spanish Language Television, Print, Digital Print, and Radio Ads for the Tips 2014 National Campaign

IC 210942 under ICR 201312-0920-001 · OMB 0920-0910.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0910 can be found here:

Documents and Forms

Document Name Document Type
Rough Cut Testing of Spanish Language Television, Print, Digital Print, and Radio Ads for the Tips 2014 National Campaign Form
1a - Screener - Spanish Att 1a Screener (Spanish) 03112013.docx Form
1b - Questionnaire - Spanish Att 1b Main Questionnaire (Spanish) 03112014.docx Form
5 - Screenshots of questionnaire Att 5_Screenshots SPANISH.pdf Form
GenIC 10_Part A_03202014.docx Supporting Statement A IC Document
GenIC 10_Part B_03202014.docx Supporting Statement B IC Document
Att 1a Screener (English).docx 1a - Screener - English IC Document
Att 1b Main Questionnaire (English).docx 1b - Questionnaire - English IC Document
Att 2_Email Recruitment (Spanish).docx 2 - Email Recruitment IC Document
Att 3_Privacy Policy (Spanish).docx 3 - Privacy Policy IC Document
Att 4_Terms and Conditions (Spanish).docx 4 - Terms and Conditions IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Rough Cut Testing of Spanish Language Television, Print, Digital Print, and Radio Ads for the Tips 2014 National Campaign	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	1a - Screener - Spanish	Att 1a Screener (Spanish) 03112013.docx	Yes	Yes	Fillable Fileable
Form	none	1b - Questionnaire - Spanish	Att 1b Main Questionnaire (Spanish) 03112014.docx	Yes	Yes	Fillable Fileable
Form	none	5 - Screenshots of questionnaire	Att 5_Screenshots SPANISH.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7,448	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	7,448	0	0	0	0	0
Annual IC Time Burden (Hours)	1,672	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement A	GenIC 10_Part A_03202014.docx	03/24/2014
Supporting Statement B	GenIC 10_Part B_03202014.docx	03/24/2014
1a - Screener - English	Att 1a Screener (English).docx	03/24/2014
1b - Questionnaire - English	Att 1b Main Questionnaire (English).docx	03/24/2014
2 - Email Recruitment	Att 2_Email Recruitment (Spanish).docx	03/24/2014
3 - Privacy Policy	Att 3_Privacy Policy (Spanish).docx	03/24/2014
4 - Terms and Conditions	Att 4_Terms and Conditions (Spanish).docx	03/24/2014

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