Information Collection

Trust, Acceptance and Confidence in Vaccines and Vaccination Schedules

IC 222327 under ICR 201506-0920-003 · OMB 0920-0222.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0222 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Trust, Acceptance and Confidence in Vaccines and Vaccination Schedules	Form and Instruction
Focus Group Screener Attachment 3 - FG Screener.docx	Form and Instruction
Cognitive Interview Screener Attachment 4 - Cognitive Interview Screener.docx	Form and Instruction
Focus Group Moderator Guide Attachment 1 - FG Moderator Guide.docx	Form and Instruction
Cognitive Interview Moderator Guide Attachment 2 - Draft Questionnaire Domains.docx	Form and Instruction
Attachment 5 - FG Informed Consent.docx Focus Group Informed Consent	IC Document
Attachment 6 - Cognitive Interview Informed Consent.docx Cognitive Interview Informed Consent	IC Document
Attachment 7 - Data Collection Sheet.docx Data Collection Sheet	IC Document
Attachment 8 - FG Special Consent.docx Focus Group - Audio/Visual Consent	IC Document
Attachment 9 - Cognitive Interview Special Consent.docx Cognitive Interview Audio/Visual Consent	IC Document
Vaccine 10-day letter_06 30 2016.docx GenIC - 10-Day Letter	IC Document

IC Title:

Trust, Acceptance and Confidence in Vaccines and Vaccination Schedules

Agency IC Tracking Number:

16AUF

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	Focus Group Screener	Attachment 3 - FG Screener.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	Cognitive Interview Screener	Attachment 4 - Cognitive Interview Screener.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	Focus Group Moderator Guide	Attachment 1 - FG Moderator Guide.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	Cognitive Interview Moderator Guide	Attachment 2 - Draft Questionnaire Domains.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0164 - Health and Demographic Surveys Conducted in Probability Samples of the U. S. Population

FR Citation: 49 FR 37693

Number of Respondents: 258

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	258	258
Annual IC Time Burden (Hours)	124	124
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Focus Group Informed Consent	Attachment 5 - FG Informed Consent.docx	07/05/2016
Cognitive Interview Informed Consent	Attachment 6 - Cognitive Interview Informed Consent.docx	07/05/2016
Data Collection Sheet	Attachment 7 - Data Collection Sheet.docx	07/05/2016
Focus Group - Audio/Visual Consent	Attachment 8 - FG Special Consent.docx	07/05/2016
Cognitive Interview Audio/Visual Consent	Attachment 9 - Cognitive Interview Special Consent.docx	07/05/2016
GenIC - 10-Day Letter	Vaccine 10-day letter_06 30 2016.docx	07/05/2016

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