Skin Cancer Messages among Racial Ethnic Groups at Risk for Delayed Diagnosis, Advanced Disease and Lower Survival

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⚠️ Notice: This information collection may be referencing outdated material.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
Skin Cancer Messages among Racial Ethnic Groups at Risk for Delayed Diagnosis, Advanced Disease and Lower Survival Form and Instruction
Screener ATTACHMENT A1 Screener_04 24 17.docx Form and Instruction
Informed Consent and Rescreening Form ATTACHMENT A2 Rescreener and Consent form_04 24 17_0248pm.docx Form and Instruction
Focus Group Discussion Guide for African American Women ATTACHMENT B1 FG Guide African American Women 04 24 17.docx Form and Instruction
Focus Group Discussion Guide for Hispanic Women ATTACHMENT B2 FG Guide Hispanic Women 04 24 17.docx Form and Instruction
Focus Group Discussion Guide for African American Men ATTACHMENT B3 FG Guide African American Male 04 24 17.docx Form and Instruction
Focus Group Discussion Guide for Hispanic Men ATTACHMENT B4 FG Guide Hispanic Men 04 24 17.docx Form and Instruction
Digital Ad Response Sheet (completed during focus groups ATTACHMENT B5 Digital Ad Response Sheet _ 04 25_17.docx Form and Instruction
ATTACHMENT C Materials for testing_04 24 17.docx Materials for Testing IC Document
HMTS_Expedited_Review_Form_nbl_Revised_4_26_17_5pm.docx HMTS Review Form for Focus Group Testing of Skin Cancer Messages IC Document

Information Collection (IC) Details

IC Title:	Skin Cancer Messages among Racial Ethnic Groups at Risk for Delayed Diagnosis, Advanced Disease and Lower Survival	Agency IC Tracking Number:	0920-17YM

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	N/A	Screener	ATTACHMENT A1 Screener_04 24 17.docx	No	Paper Only
Form and Instruction	N/A	Informed Consent and Rescreening Form	ATTACHMENT A2 Rescreener and Consent form_04 24 17_0248pm.docx	No	Paper Only
Form and Instruction	N/A	Focus Group Discussion Guide for African American Women	ATTACHMENT B1 FG Guide African American Women 04 24 17.docx	No	Paper Only
Form and Instruction	N/A	Focus Group Discussion Guide for Hispanic Women	ATTACHMENT B2 FG Guide Hispanic Women 04 24 17.docx	No	Paper Only
Form and Instruction	N/A	Focus Group Discussion Guide for African American Men	ATTACHMENT B3 FG Guide African American Male 04 24 17.docx	No	Paper Only
Form and Instruction	N/A	Focus Group Discussion Guide for Hispanic Men	ATTACHMENT B4 FG Guide Hispanic Men 04 24 17.docx	No	Paper Only
Form and Instruction	N/A	Digital Ad Response Sheet (completed during focus groups with men)	ATTACHMENT B5 Digital Ad Response Sheet _ 04 25_17.docx	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 756	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	756	756
Annual IC Time Burden (Hours)	398	398
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Materials for Testing	ATTACHMENT C Materials for testing_04 24 17.docx	04/24/2017
HMTS Review Form for Focus Group Testing of Skin Cancer Messages	HMTS_Expedited_Review_Form_nbl_Revised_4_26_17_5pm.docx	04/25/2017

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