Information Collection

Asthma Control Communication Materials Field Testing (NCEH)

IC 230191 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⚠️ Notice: This information collection may be referencing outdated material.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
Asthma Control Communication Materials Field Testing (NCEH)	Form and Instruction
Attachment 2_Focus Group Discussion Guide.docx	Other-Discussion Guide
Foduc Group Screener Attachment 1_Focus Group Screener.docx	Form and Instruction
Youth Rating Worksheet Attachment 3_Focus Group Rating Worksheet_Youth.docx	Form and Instruction
Caregiver Rating Worksheet Attachment 4_Focus Group Rating Worksheet_Caregiver.docx	Form and Instruction
Youth Comparison Worksheet Attachment 5_Focus Group Comparison Worksheet_Youth.docx	Form and Instruction
Caregiver Comparison Worksheet Attachment 6_Focus Group Comparison Worksheet_Caregiver.docx	Form and Instruction
HMTSExpeditedReviewForm_Asthma Control Communication Materials Field Testing.pdf HTMS Review Form	IC Document
PrjctDscrptn_Asthma Control Communication Materials Field Testing.docx Project Description	IC Document
Attachment 8_Focus Group Youth Assent Form.docx Youth Assent	IC Document
Attachment 7_Focus Group Caregiver for Youth Permission Form.docx Caregiver Permission for Youth	IC Document
Attachment 9_Focus Group Caregiver Consent Form.docx Caregiver Consent	IC Document
Attachment 10_Focus Group Confirmation Email.docx Fogus Group Confirmation Email	IC Document
Attachment 11_Focus Group Reminder Email.docx Focus Group Reminder Email	IC Document
Attachment 12_Focus Group Message Stimuli.pptx Focus Group Message Stimuli	IC Document
List of Attachments.docx List of Attachments	IC Document

IC Title:

Asthma Control Communication Materials Field Testing (NCEH)

Agency IC Tracking Number:

0920-0572-18QD

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	none	Foduc Group Screener	Attachment 1_Focus Group Screener.docx	Yes	No	Paper Only
Other-Discussion Guide			Attachment 2_Focus Group Discussion Guide.docx	Yes	No	Paper Only
Form and Instruction	none	Youth Rating Worksheet	Attachment 3_Focus Group Rating Worksheet_Youth.docx	Yes	No	Paper Only
Form and Instruction	none	Caregiver Rating Worksheet	Attachment 4_Focus Group Rating Worksheet_Caregiver.docx	Yes	No	Paper Only
Form and Instruction	none	Youth Comparison Worksheet	Attachment 5_Focus Group Comparison Worksheet_Youth.docx	Yes	No	Paper Only
Form and Instruction	none	Caregiver Comparison Worksheet	Attachment 6_Focus Group Comparison Worksheet_Caregiver.docx	Yes	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 448

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	448	448
Annual IC Time Burden (Hours)	128	128
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
HTMS Review Form	HMTSExpeditedReviewForm_Asthma Control Communication Materials Field Testing.pdf	02/20/2018
Project Description	PrjctDscrptn_Asthma Control Communication Materials Field Testing.docx	02/20/2018
Youth Assent	Attachment 8_Focus Group Youth Assent Form.docx	02/20/2018
Caregiver Permission for Youth	Attachment 7_Focus Group Caregiver for Youth Permission Form.docx	02/20/2018
Caregiver Consent	Attachment 9_Focus Group Caregiver Consent Form.docx	02/20/2018
Fogus Group Confirmation Email	Attachment 10_Focus Group Confirmation Email.docx	02/20/2018
Focus Group Reminder Email	Attachment 11_Focus Group Reminder Email.docx	02/20/2018
Focus Group Message Stimuli	Attachment 12_Focus Group Message Stimuli.pptx	02/20/2018
List of Attachments	List of Attachments.docx	02/20/2018

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