Information Collection

Wellness Materials Concept Testing

IC 224310 under ICR 201608-0930-002 · OMB 0930-0196.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0196 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Wellness screening Wellness Materials Concept Testing	Form and Instruction
Wellness screening Wellness screening and recruitment 2016_11_03_Attachment B - Wellness screening and recruitment.docx	Form and Instruction
2016_11_03_Attachment A - Wellness Focus Groups Protocol.docx Wellness Focus Group Protocol	IC Document
2016_11_03_Attachment C - Wellness Consent Form.docx Wellness Consent Form	IC Document
2016_11_03_Attachment D - FGD Wellness Facilitator Guide.docx Wellness Focus Group Facilitator Guide	IC Document
2016_11_03_Wellness OMB package_Supporting Statements.docx Justification	IC Document
TransLet-1doc.doc Transmittal Letter	IC Document

IC Title:

Wellness Materials Concept Testing

Agency IC Tracking Number:

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	Wellness screening and recruitment	Wellness screening and recruitment	2016_11_03_Attachment B - Wellness screening and recruitment.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	84	84
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Wellness Focus Group Protocol	2016_11_03_Attachment A - Wellness Focus Groups Protocol.docx	11/03/2016
Wellness Consent Form	2016_11_03_Attachment C - Wellness Consent Form.docx	11/03/2016
Wellness Focus Group Facilitator Guide	2016_11_03_Attachment D - FGD Wellness Facilitator Guide.docx	11/03/2016
Justification	2016_11_03_Wellness OMB package_Supporting Statements.docx	11/03/2016
Transmittal Letter	TransLet-1doc.doc	11/03/2016

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