Information Collection

HEADS UP Audience Research Study

IC 221338 under ICR 201502-0920-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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
HEADS UP Audience Research Study	Form and Instruction
FOCUS GROUP SCREENER AND FOLLOW UP FOCUS GROUP SCREENER Attachment B_Screener.docx	Form and Instruction
FOCUS GROUP AND FOLLOW UP FOCUS GROUP INSTRUMENT Attachment C_Instruments.docx	Form and Instruction
Attachment E_Burden Table.docx Burden Table	IC Document
Attachment A_Project Description.docx Project Description	IC Document
Attachment D_Informed Consent.docx Informed Consent	IC Document
genic List of Attachments_FG.DOCX List of Attachments	IC Document
HMTSExpeditedReviewForm_03MAY2016.pdf HMTS Expedited Review Form	IC Document

IC Title:

HEADS UP Audience Research Study

Agency IC Tracking Number:

16AGZ

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	NA	FOCUS GROUP SCREENER AND FOLLOW UP FOCUS GROUP SCREENER	Attachment B_Screener.docx	NA	No		Paper Only
Form and Instruction	NA	FOCUS GROUP AND FOLLOW UP FOCUS GROUP INSTRUMENT	Attachment C_Instruments.docx	NA	No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 280

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	280	280
Annual IC Time Burden (Hours)	165	165
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Burden Table	Attachment E_Burden Table.docx	05/03/2016
Project Description	Attachment A_Project Description.docx	05/03/2016
Informed Consent	Attachment D_Informed Consent.docx	05/03/2016
List of Attachments	genic List of Attachments_FG.DOCX	05/03/2016
HMTS Expedited Review Form	HMTSExpeditedReviewForm_03MAY2016.pdf	05/03/2016

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