Information Collection

Assessing the Effectiveness of HEADS UP Message

IC 221119 under ICR 201405-0920-002 · OMB 0920-1009.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1009 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1009 Assessing the Effectiveness of HEADS UP Message	Form and Instruction
0920-1009 Attachment A_Screener Attachment A_Screener.docx	Form and Instruction
0920-1009 Attachment B_Instrument Attachment B_Instrument.docx	Form and Instruction
Attachment D_Informed Consent.docx Attachment C_Survey Screenshots	IC Document
Attachment D_Informed Consent.docx Attachment D_Informed Consent	IC Document
GenIC Request_Improving TBI Message_ICRO.docx GenIC Request_Improving TBI Message_	IC Document

IC Title:

Assessing the Effectiveness of HEADS UP Message

Agency IC Tracking Number:

16ABH

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	0920-1009	Attachment A_Screener	Attachment A_Screener.docx		Yes	Yes	Fillable Printable
Form and Instruction	0920-1009	Attachment B_Instrument	Attachment B_Instrument.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 400

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	400	400
Annual IC Time Burden (Hours)	40	40
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment C_Survey Screenshots	Attachment D_Informed Consent.docx	04/19/2016
Attachment D_Informed Consent	Attachment D_Informed Consent.docx	04/19/2016
GenIC Request_Improving TBI Message_	GenIC Request_Improving TBI Message_ICRO.docx	04/19/2016

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