Information Collection

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

IC 230309 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⚠️ Notice: This information collection may be referencing outdated material.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
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

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:

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.