"Bring Your Brave" Campaign Messages for Young Women and Health Care Providers

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⚠️ Notice: This information collection may be referencing outdated material.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
Form 0920-0572 "Bring Your Brave" Campaign Messages for Young Women and Health Care Providers Form and Instruction
0920-0572 Screening Instrument for Young Women Attachment_B1_Screener_for_Young_Women.docx Form and Instruction
0920-0572 Survey Instrument for Young Women Attachment_C1_Survey_for_Young_Women.docx Form and Instruction
0920-0572 Screening Instrument for Health Care Providers Attachment_B2_Screener_for_Health_Care_Providers.docx Form and Instruction
0920-0572 Survey Instrument for Health Care Providers Attachment_C2_Survey_for_Health_Care_Providers.docx Form and Instruction
Attachment_A_Protocol_Summary_2.6.18 23 minutes.docx Protocol Summary IC Document
Attachment_D_Participant_Information_Sheet.docx Participant Information Sheet IC Document
Attachment_E1_Materials_for_Young_Women.docx Materials to be Tested for Young Women IC Document
Attachment_E2_Materials_Health_Care_Providers.docx Materials to be Tested for Health Care Providers IC Document
HMTSExpeditedReviewForm_WORD 06MAR2018.docx HMTS Expedited Review Form IC Document

Information Collection (IC) Details

IC Title:	"Bring Your Brave" Campaign Messages for Young Women and Health Care Providers	Agency IC Tracking Number:	0920-0572-18TR

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-0572	Screening Instrument for Young Women	Attachment_B1_Screener_for_Young_Women.docx	NA	No		Fillable Fileable
Form and Instruction	0920-0572	Survey Instrument for Young Women	Attachment_C1_Survey_for_Young_Women.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0572	Screening Instrument for Health Care Providers	Attachment_B2_Screener_for_Health_Care_Providers.docx	NA	No		Fillable Fileable
Form and Instruction	0920-0572	Survey Instrument for Health Care Providers	Attachment_C2_Survey_for_Health_Care_Providers.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 600	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 90 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	600	600
Annual IC Time Burden (Hours)	164	164
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Protocol Summary	Attachment_A_Protocol_Summary_2.6.18 23 minutes.docx	03/06/2018
Participant Information Sheet	Attachment_D_Participant_Information_Sheet.docx	03/06/2018
Materials to be Tested for Young Women	Attachment_E1_Materials_for_Young_Women.docx	03/06/2018
Materials to be Tested for Health Care Providers	Attachment_E2_Materials_Health_Care_Providers.docx	03/06/2018
HMTS Expedited Review Form	HMTSExpeditedReviewForm_WORD 06MAR2018.docx	03/06/2018

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