Information Collection

Educational Game Focus Group

IC 216184 under ICR 201501-0925-004 · OMB 0925-0648.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0648 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Educational Game Focus Group	Form and Instruction
1 Screeners Attachment_1_Screener_3_25_15.docx	Form and Instruction
2 Clinical Professional Consent Form and Script Attachment_2_Clinical Trial Professional Consent Script 3_25_15.doc	Form and Instruction
3 Teacher Consent Form and Script Attachment_3_Teacher Consent Script 3_25_15.doc	Form and Instruction
4 Parent Consent Form and Scriot Attachment_4_Parent Consent Script 3_25_15.doc	Form and Instruction
5 Child Assent Form Attachment_5_Child Assent Script 3_25_15.doc	Form and Instruction
Revised Fast Track submission Form 04_16_15.doc Fast Track Submission Form	IC Document
Attachment 6 Invitation Letters for all Respondents 3_29_15.docx Focus Group Invitation Letter	IC Document

IC Title:

Educational Game Focus Group

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	1	Screeners	Attachment_1_Screener_3_25_15.docx	Yes	Yes	Printable Only
Form and Instruction	2	Clinical Professional Consent Form and Script	Attachment_2_Clinical Trial Professional Consent Script 3_25_15.doc	Yes	Yes	Fillable Fileable
Form and Instruction	3	Teacher Consent Form and Script	Attachment_3_Teacher Consent Script 3_25_15.doc	Yes	Yes	Fillable Fileable
Form and Instruction	4	Parent Consent Form and Scriot	Attachment_4_Parent Consent Script 3_25_15.doc	Yes	Yes	Fillable Fileable
Form and Instruction	5	Child Assent Form	Attachment_5_Child Assent Script 3_25_15.doc	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 32

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	32	32
Annual IC Time Burden (Hours)	32	32
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Fast Track Submission Form	Revised Fast Track submission Form 04_16_15.doc	04/17/2015
Focus Group Invitation Letter	Attachment 6 Invitation Letters for all Respondents 3_29_15.docx	04/17/2015

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