Audience Research on Self-Management Education

CDC and ATSDR Health Message Testing System

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0572 can be found here:

Documents and Forms

Document Name Document Type
Audience Research on Self-Management Education Form and Instruction
Moderator's Guide Attachment 3 - Moderators Guide 052313.docx Form and Instruction
Screener Attachment 2 - Eligibility Screener 052313.docx Form and Instruction
Attachment 4- Informed Consent Form 052313.docx Consent IC Document
Attachment 5 - Materials 052313.docx Materials IC Document
DPH_HMTS Expedited Review Form 052313.docx Expedited Review Form IC Document
Attachment 1 - Research Plan - Burden Table 052313.docx Supporting Information IC Document
List of Attachments 052313.docx List of Attachments IC Document

Information Collection (IC) Details

IC Title:	Audience Research on Self-Management Education	Agency IC Tracking Number:

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	none	Moderator's Guide	Attachment 3 - Moderators Guide 052313.docx		No	No	Printable Only
Form and Instruction	none	Screener	Attachment 2 - Eligibility Screener 052313.docx		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 120	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Previously Approved
Annual Number of Responses for this IC	120	120
Annual IC Time Burden (Hours)	200	200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Consent	Attachment 4- Informed Consent Form 052313.docx	05/29/2013
Materials	Attachment 5 - Materials 052313.docx	05/29/2013
Expedited Review Form	DPH_HMTS Expedited Review Form 052313.docx	05/29/2013
Supporting Information	Attachment 1 - Research Plan - Burden Table 052313.docx	05/29/2013
List of Attachments	List of Attachments 052313.docx	05/29/2013

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