Information Collection

Message and Material Testing for the Get Ahead of Sepsis (GAOS) Campaign for Consumer Audiences

IC 237889 under ICR 201806-0920-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Message and Material Testing for the Get Ahead of Sepsis (GAOS) Campaign for Consumer Audiences	Form and Instruction
0920-0572 Cancer Patients and Caregivers Mod Guide Sepsis Consumer Mod Guide - Cancer patients and caregivers_09.27.19.docx	Form and Instruction
0920-0572 Men Aged 65 and Older Mod Guide Sepsis Consumer Mod Guide - Men aged 65 and older_09.27.19.docx	Form and Instruction
0920-0572 Sepsis Survivors and Caregivers Mod Guide Sepsis Consumer Mod Guide - Sepsis survivors and caregivers_09.27.19.docx	Form and Instruction
0920-0572 Women Who Care for Aging Parent Mod Guide Sepsis Consumer Mod Guide - Women who care for aging parent_09.27.19.docx	Form and Instruction
0920-0572 Women Who Care for Child Mod Guide Sepsis Consumer Mod Guide - Women who care for child_09.27.19.docx	Form and Instruction
0920-0572 Women Who Primarily Speak Spanish Mod Guide En Sepsis Consumer Mod Guide - Women who speak Spanish_EN_09.27.19.docx	Form and Instruction
0920-0572 Cancer Patients Screener Sepsis Consumer Screener - Cancer patients_10.1.19.docx	Form and Instruction
0920-0572 Caregivers to Cancer Screener Sepsis Consumer Screener - Caregivers to cancer_10.1.19.docx	Form and Instruction
0920-0572 Caregivers to Sepsis Survivors Screener Sepsis Consumer Screener - Caregivers to sepsis survivors_10.1.19.docx	Form and Instruction
0920-0572 Men Aged 65 and Older Screener Sepsis Consumer Screener - Men aged 65 and older_10.1.19.docx	Form and Instruction
0920-0572 Sepsis Survivors Screener Sepsis Consumer Screener - Sepsis Survivors_10.1.19.docx	Form and Instruction
0920-0572 Women who Care for Aging Parent Screener Sepsis Consumer Screener - Women who care for aging parent_10.1.19.docx	Form and Instruction
0920-0572 Women Who Care for Child Screener Sepsis Consumer Screener - Women who care for child_10.1.19.docx	Form and Instruction
0920-0572 Women Who Speak Spanish Screener (Eng) Sepsis Consumer Screener - Women who speak Spanish_EN_10.1.19.docx	Form and Instruction
HMTS Expedited Review Form_Sepsis Consumer final.pdf Expedited Review Form	IC Document
HMTS Expedited Review Form_Attachment A_Sepsis Consumer.docx Study Population	IC Document
HMTS Expedited Review Form_Attachment B_Sepsis Consumer 09.27.19.docx Incentives Summary	IC Document
IRB Exempt Approval Documents_Sepsis Consumer.pdf IRB	IC Document
Sepsis Consumer Mod Guide - Women who speak Spanish_SP_09.27.19.docx Women Who Primarily Speak Spanish Mod Guide Sp	IC Document
Sepsis Consumer Screener - Women who speak Spanish_SP 10.1.19.docx Women Who Speak Spanish Screener (Sp)	IC Document
Sepsis Consumer Informed Consent.docx Informed Consent	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Message and Material Testing for the Get Ahead of Sepsis (GAOS) Campaign for Consumer Audiences

Agency IC Tracking Number:

0920-0572-19BSE

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	Available Electronically?	Electronic Capability
Form and Instruction	0920-0572	Cancer Patients and Caregivers Mod Guide	Sepsis Consumer Mod Guide - Cancer patients and caregivers_09.27.19.docx	No	Fillable Fileable
Form and Instruction	0920-0572	Men Aged 65 and Older Mod Guide	Sepsis Consumer Mod Guide - Men aged 65 and older_09.27.19.docx	No	Fillable Fileable
Form and Instruction	0920-0572	Sepsis Survivors and Caregivers Mod Guide	Sepsis Consumer Mod Guide - Sepsis survivors and caregivers_09.27.19.docx	No	Fillable Fileable
Form and Instruction	0920-0572	Women Who Care for Aging Parent Mod Guide	Sepsis Consumer Mod Guide - Women who care for aging parent_09.27.19.docx	No	Fillable Fileable
Form and Instruction	0920-0572	Women Who Care for Child Mod Guide	Sepsis Consumer Mod Guide - Women who care for child_09.27.19.docx	No	Fillable Fileable
Form and Instruction	0920-0572	Women Who Primarily Speak Spanish Mod Guide En	Sepsis Consumer Mod Guide - Women who speak Spanish_EN_09.27.19.docx	No	Fillable Fileable
Form and Instruction	0920-0572	Cancer Patients Screener	Sepsis Consumer Screener - Cancer patients_10.1.19.docx	No	Fillable Fileable
Form and Instruction	0920-0572	Caregivers to Cancer Screener	Sepsis Consumer Screener - Caregivers to cancer_10.1.19.docx	No	Fillable Fileable
Form and Instruction	0920-0572	Caregivers to Sepsis Survivors Screener	Sepsis Consumer Screener - Caregivers to sepsis survivors_10.1.19.docx	No	Fillable Fileable
Form and Instruction	0920-0572	Men Aged 65 and Older Screener	Sepsis Consumer Screener - Men aged 65 and older_10.1.19.docx	No	Fillable Fileable
Form and Instruction	0920-0572	Sepsis Survivors Screener	Sepsis Consumer Screener - Sepsis Survivors_10.1.19.docx	No	Fillable Fileable
Form and Instruction	0920-0572	Women who Care for Aging Parent Screener	Sepsis Consumer Screener - Women who care for aging parent_10.1.19.docx	No	Fillable Fileable
Form and Instruction	0920-0572	Women Who Care for Child Screener	Sepsis Consumer Screener - Women who care for child_10.1.19.docx	No	Fillable Fileable
Form and Instruction	0920-0572	Women Who Speak Spanish Screener (Eng)	Sepsis Consumer Screener - Women who speak Spanish_EN_10.1.19.docx	No	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 696

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 10 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	696	696
Annual IC Time Burden (Hours)	186	186
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Expedited Review Form	HMTS Expedited Review Form_Sepsis Consumer final.pdf	09/27/2019
Study Population	HMTS Expedited Review Form_Attachment A_Sepsis Consumer.docx	10/01/2019
Incentives Summary	HMTS Expedited Review Form_Attachment B_Sepsis Consumer 09.27.19.docx	10/01/2019
IRB	IRB Exempt Approval Documents_Sepsis Consumer.pdf	09/27/2019
Women Who Primarily Speak Spanish Mod Guide Sp	Sepsis Consumer Mod Guide - Women who speak Spanish_SP_09.27.19.docx	10/01/2019
Women Who Speak Spanish Screener (Sp)	Sepsis Consumer Screener - Women who speak Spanish_SP 10.1.19.docx	10/02/2019
Informed Consent	Sepsis Consumer Informed Consent.docx	10/02/2019

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