Wellness Materials Concept Testing

Pretesting of Substance Abuse Prevention and Treatment and Mental Health Services Communications Messages

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Wellness Materials Concept Testing	Agency IC Tracking Number:

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	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 %

	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

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.