Information Collection

High Impact Prevention Message Testing (HIPMT)

IC 221856 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⚠️ Notice: This information collection may be referencing outdated material.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
High Impact Prevention Message Testing (HIPMT)	Form and Instruction
Consumer Focus Group Guide Att 2A Consumer Focus Group Guide.docx	Form and Instruction
Consumer IDI Guide Att 2B Consumer IDI Guide.docx	Form and Instruction
Provider Focus Group Guide Att 3A Provider Focus Group Guide.docx	Form and Instruction
Provider IDI Guide Att 3B Provider IDI Guide.docx	Form and Instruction
Professional Focus Group Guide Att 4A Professional Focus Group Guide.docx	Form and Instruction
Professional IDI Guide Att 4B Professional IDI.DOCX	Form and Instruction
Consumer - Brief Survey Att 6 Brief survey - Consumer IDI FG.DOCX	Form and Instruction
Provider - Brief Survey Att 7 Brief Survey - Provider IDI FG.DOCX	Form and Instruction
Professional - Brief Survey Att 8 Brief Survey - Professional IDI FG.DOCX	Form and Instruction
Consumer - Screener Att 10 Screener Consumer IDI FG.DOCX	Form and Instruction
Provider - Screener Att 11 Screener Provider IDI FG.DOCX	Form and Instruction
Professional - Screener Att 12 Screener Professional IDI FG.DOCX	Form and Instruction
Consumer - Consent Att 14 Consent Consumer IDI FG.DOCX	Form and Instruction
Provider - Consent Att 18 Consent Provider IDI FG.DOCX	Form and Instruction
Professional - Consent Att 16 Consent Professional IDI FG.DOCX	Form and Instruction
Consumer Web Survey Att 9 Consumer Web Survey.docx	Form and Instruction
Intercept Guide Att 5 Intercept Guide.docx	Form and Instruction
Screener - Consumer Web Survey Att 13 Screener Consumer Web Survey.docx	Form and Instruction
Consent - Consumer Web Survey Att 13 Screener Consumer Web Survey.docx	Form and Instruction
Consent - Intercept Survey Att 17 Consent Intercept.docx	Form and Instruction
Att 19 Web Survey Consumer E-mail Notification.docx Consumer Web Survey Email Notification	IC Document
Att 20 Intercept Receipt Form.docx Intercept Interview Receipt Form	IC Document
Att 23 Messages to Test.docx HIPMT Messages to be Tested	IC Document
Att 21 Justification for Incentives_Revised 09JUN2016.docx Incentive Justification - Revised	IC Document
HMTS Expedited Review Form_HIPMT-revised 09JUN2016.pdf HMTS - Expedited Review Form Revised	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

High Impact Prevention Message Testing (HIPMT)

Agency IC Tracking Number:

16AOS

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	Consumer Focus Group Guide	Att 2A Consumer Focus Group Guide.docx	NA	No		Paper Only
Form and Instruction	NA	Consumer IDI Guide	Att 2B Consumer IDI Guide.docx	NA	No		Paper Only
Form and Instruction	NA	Provider Focus Group Guide	Att 3A Provider Focus Group Guide.docx	NA	No		Paper Only
Form and Instruction	NA	Provider IDI Guide	Att 3B Provider IDI Guide.docx	NA	No		Paper Only
Form and Instruction	NA	Professional Focus Group Guide	Att 4A Professional Focus Group Guide.docx	NA	No		Paper Only
Form and Instruction	NA	Professional IDI Guide	Att 4B Professional IDI.DOCX	NA	No		Paper Only
Form and Instruction	NA	Consumer - Brief Survey	Att 6 Brief survey - Consumer IDI FG.DOCX	NA	No		Paper Only
Form and Instruction	NA	Provider - Brief Survey	Att 7 Brief Survey - Provider IDI FG.DOCX	NA	No		Paper Only
Form and Instruction	NA	Professional - Brief Survey	Att 8 Brief Survey - Professional IDI FG.DOCX	NA	No		Paper Only
Form and Instruction	NA	Consumer - Screener	Att 10 Screener Consumer IDI FG.DOCX	NA	No		Paper Only
Form and Instruction	NA	Provider - Screener	Att 11 Screener Provider IDI FG.DOCX	NA	No		Paper Only
Form and Instruction	NA	Professional - Screener	Att 12 Screener Professional IDI FG.DOCX	NA	No		Paper Only
Form and Instruction	NA	Consumer - Consent	Att 14 Consent Consumer IDI FG.DOCX	NA	No		Paper Only
Form and Instruction	NA	Provider - Consent	Att 18 Consent Provider IDI FG.DOCX	NA	No		Paper Only
Form and Instruction	NA	Professional - Consent	Att 16 Consent Professional IDI FG.DOCX	NA	No		Paper Only
Form and Instruction	NA	Consumer Web Survey	Att 9 Consumer Web Survey.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	Intercept Guide	Att 5 Intercept Guide.docx	NA	No		Paper Only
Form and Instruction	NA	Screener - Consumer Web Survey	Att 13 Screener Consumer Web Survey.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	Consent - Consumer Web Survey	Att 13 Screener Consumer Web Survey.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	Consent - Intercept Survey	Att 17 Consent Intercept.docx	NA	No		Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 900

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 45 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	900	900
Annual IC Time Burden (Hours)	692	692
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Consumer Web Survey Email Notification	Att 19 Web Survey Consumer E-mail Notification.docx	06/09/2016
Intercept Interview Receipt Form	Att 20 Intercept Receipt Form.docx	06/09/2016
HIPMT Messages to be Tested	Att 23 Messages to Test.docx	06/09/2016
Incentive Justification - Revised	Att 21 Justification for Incentives_Revised 09JUN2016.docx	06/09/2016
HMTS - Expedited Review Form Revised	HMTS Expedited Review Form_HIPMT-revised 09JUN2016.pdf	06/09/2016

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