Information Collection

Audience Research on Self-Management Education, Phase III

IC 213762 under ICR 201501-0920-003 · OMB 0920-0572.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0572 Audience Research on Self-Management Education, Phase III	Form and Instruction
0920-0572 Attachment 4 Screener_10282014 Attachment 4 Screener_10282014.docx	Form and Instruction
0920-0572 Attachment 3 Mod Guide_10282014 Attachment 3 Mod Guide_10282014.docx	Form and Instruction
Attachment 1 Research Plan and Burden_10282014.docx Attachment 1 Research Plan and Burden_10282014	IC Document
Attachment 2 Materials_v3 10282014.docx Attachment 2 Materials_v3 10282014	IC Document
Attachment 5 Consent_10 27.docx Attachment 5 Consent_10 27	IC Document
HMTS Expedited Review Form_SME 10282014 V3.docx HMTS Expedited Review Form_SME 10282014 V3	IC Document

IC Title:

Audience Research on Self-Management Education, Phase III

Agency IC Tracking Number:

0920-15DC

IC Status: Unchanged

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	0920-0572	Attachment 4 Screener_10282014	Attachment 4 Screener_10282014.docx		Yes	Yes	Fillable Printable
Form and Instruction	0920-0572	Attachment 3 Mod Guide_10282014	Attachment 3 Mod Guide_10282014.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 160

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	160	160
Annual IC Time Burden (Hours)	134	134
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 1 Research Plan and Burden_10282014	Attachment 1 Research Plan and Burden_10282014.docx	11/10/2014
Attachment 2 Materials_v3 10282014	Attachment 2 Materials_v3 10282014.docx	11/10/2014
Attachment 5 Consent_10 27	Attachment 5 Consent_10 27.docx	11/10/2014
HMTS Expedited Review Form_SME 10282014 V3	HMTS Expedited Review Form_SME 10282014 V3.docx	11/10/2014

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