Information Collection

Message Testing for Diabetes Self-Management Education and Support (DSMES) Branding: Cart Sort Activity

IC 238018 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⚠️ Notice: This information collection may be referencing outdated material.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 Testing for Diabetes Self-Management Education and Support (DSMES) Branding: Cart Sort Activity	Form and Instruction
0920-0572 Screener Diabetes Educators File 3 Card Sort Screeners Diabetes Educators 2 .docx	Form and Instruction
0920-0572 Screener Health Care Providers File 4 Card Sort Screeners Health care providers 2.docx	Form and Instruction
0920-0572 Screener People with DM File 5 Card Sort Screeners People with DM 2.docx	Form and Instruction
0920-0572 Diabetes Educators Survey File 7 -CARD SORT instrument Word Diabetes educators.docx	Form and Instruction
0920-0572 Health Care Providers Survey File 8 -CARD SORT instrument Word Health care providers.docx	Form and Instruction
0920-0572 Person with DM had DSMES Survey File 9 - CARD SORT instrument Word Person with DM Had DSMES.docx	Form and Instruction
0920-0572 Person with DM not had DSMES Survey File 10 - CARD SORT instrument Word Person with DM Not Had DSMES.docx	Form and Instruction
File 1 - HMTSExpeditedReviewForm for card sort.pdf Expedited Review Form	IC Document
File 2 HMTS Expedited Review Supplement - DSMES Card Sort 2.docx Expedited Review Supplement	IC Document
File 6 -Card Sort Informed Consent Screenshots.docx Informed Consent Screenshots	IC Document
File 11 - Card Sort Instrument Screenshots_Diabetes Educators.docx Diabetes Educators Survey Screenshots	IC Document
File 12 - Card Sort Instrument Screenshots_Health Care Providers.docx Healthcare Providers Survey Screenshot	IC Document
File 13 - Card Sort Instrument Screenshots_Person with DM Had DSMES.docx Person with DM had DSMES Screenshot	IC Document
File 14 - Card Sort Instrument Screenshots_Person with DM Not Had DSMES.docx Person with DM no DSMES Screenshot	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Message Testing for Diabetes Self-Management Education and Support (DSMES) Branding: Cart Sort Activity

Agency IC Tracking Number:

0920-0572-20AA

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?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-0572	Screener Diabetes Educators	File 3 Card Sort Screeners Diabetes Educators 2 .docx	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0572	Screener Health Care Providers	File 4 Card Sort Screeners Health care providers 2.docx	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0572	Screener People with DM	File 5 Card Sort Screeners People with DM 2.docx	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0572	Diabetes Educators Survey	File 7 -CARD SORT instrument Word Diabetes educators.docx	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0572	Health Care Providers Survey	File 8 -CARD SORT instrument Word Health care providers.docx	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0572	Person with DM had DSMES Survey	File 9 - CARD SORT instrument Word Person with DM Had DSMES.docx	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0572	Person with DM not had DSMES Survey	File 10 - CARD SORT instrument Word Person with DM Not Had DSMES.docx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,400

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	1,400	1,400
Annual IC Time Burden (Hours)	150	150
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Expedited Review Form	File 1 - HMTSExpeditedReviewForm for card sort.pdf	10/07/2019
Expedited Review Supplement	File 2 HMTS Expedited Review Supplement - DSMES Card Sort 2.docx	10/09/2019
Informed Consent Screenshots	File 6 -Card Sort Informed Consent Screenshots.docx	10/07/2019
Diabetes Educators Survey Screenshots	File 11 - Card Sort Instrument Screenshots_Diabetes Educators.docx	10/07/2019
Healthcare Providers Survey Screenshot	File 12 - Card Sort Instrument Screenshots_Health Care Providers.docx	10/07/2019
Person with DM had DSMES Screenshot	File 13 - Card Sort Instrument Screenshots_Person with DM Had DSMES.docx	10/07/2019
Person with DM no DSMES Screenshot	File 14 - Card Sort Instrument Screenshots_Person with DM Not Had DSMES.docx	10/07/2019

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