Information Collection

Assessment for the Get Ahead of Sepsis Consumer Campaign

IC 239892 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⚠️ Notice: This information collection may be referencing outdated material.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 Assessment for the Get Ahead of Sepsis Consumer Campaign	Form and Instruction
0920-0572 GAOS Consumer Survey Pre-test HMTS Attachment D_GAOS Consumer Survey PRE-TEST HMTS.pdf	Form and Instruction
0920-0572 GAOS Consumer Survey Post-test HMTS Attachment F_GAOS Consumer Survey POST-TEST HMTS.pdf	Form and Instruction
Attachment A_GAOS Pilot Assessment Overview_Consumers.docx GAOS Overview Consumers	IC Document
Attachment B_GAOS Consumer Recruitment Invitation final.docx Consumer Recruitment Invitation	IC Document
Attachment C_GAOS Consumer Survey_1.24.20_FINAL PRETEST.docx Pretest Instrument Word version	IC Document
Attachment E_GAOS Consumer Survey_1.24.20_FINAL POSTTEST.docx Posttest Instrument Word version	IC Document
Attachment G_GAOS Consumer and HCP Exempt 12.20.19.pdf Human Subjects Determination	IC Document
Attachment H_GAOS Consumer Materials for 2020 Assessment FINAL.pdf GAOS Consumer Materials for Assessment	IC Document
HMTS Expedited Review Form - GAOS Consumer Assessment final.pdf HMTS Expedited Review Form GAOS	IC Document

IC Title:

Assessment for the Get Ahead of Sepsis Consumer Campaign

Agency IC Tracking Number:

0920-0572-20HL

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	0920-0572	GAOS Consumer Survey Pre-test HMTS	Attachment D_GAOS Consumer Survey PRE-TEST HMTS.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	0920-0572	GAOS Consumer Survey Post-test HMTS	Attachment F_GAOS Consumer Survey POST-TEST HMTS.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 360

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	360	360
Annual IC Time Burden (Hours)	90	90
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
GAOS Overview Consumers	Attachment A_GAOS Pilot Assessment Overview_Consumers.docx	02/26/2020
Consumer Recruitment Invitation	Attachment B_GAOS Consumer Recruitment Invitation final.docx	02/26/2020
Pretest Instrument Word version	Attachment C_GAOS Consumer Survey_1.24.20_FINAL PRETEST.docx	02/26/2020
Posttest Instrument Word version	Attachment E_GAOS Consumer Survey_1.24.20_FINAL POSTTEST.docx	02/26/2020
Human Subjects Determination	Attachment G_GAOS Consumer and HCP Exempt 12.20.19.pdf	02/26/2020
GAOS Consumer Materials for Assessment	Attachment H_GAOS Consumer Materials for 2020 Assessment FINAL.pdf	02/26/2020
HMTS Expedited Review Form GAOS	HMTS Expedited Review Form - GAOS Consumer Assessment final.pdf	02/26/2020

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