Information Collection

Brand Concept Testing for Diabetes Self-Management Education and Support (DSMES) Services Marketing Support

IC 242658 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⚠️ Notice: This information collection may be referencing outdated material.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 Brand Concept Testing for Diabetes Self-Management Education and Support (DSMES) Services Marketing Support	Form and Instruction
0920-0572 PWD Screener for Focus Groups 1b--DSMES Brand Concept Testing_PWD Screener Focus Groups_for OMB.docx	Form and Instruction
0920-0572 PWD Focus Group Moderators Guide 1c--DSMES Brand Concept Testing - FG Moderators Guide for OMB.docx	Form and Instruction
0920-0572 PWD Screener Online Survey 2b--DSMES Brand Concept Testing_PWD Screener Survey_for OMB.docx	Form and Instruction
0920-0572 PWD Online Survey 2c--DSMES Brand Concept Testing PWD Survey_for OMB.docx	Form and Instruction
0920-0572 HCP Screener In Depth Interview 3a--DSMES Brand Concept Testing_HCP Screener IDI for OMB.docx	Form and Instruction
0920-0572 HCP In Depth Interview Guide 3b--DSMES Brand Concept Testing - IDI Guide- for OMB.docx	Form and Instruction
0920-0572 HCP Screener Online Survey 4b--DSMES Brand Concept Testing_HCP Screener Survey for OMB rev.docx	Form and Instruction
0920-0572 HCP Online Survey 4c--DSMES Brand Concept Testing HCP Survey for OMB.docx	Form and Instruction
1a--DSMES Brand Concept Testing Informed Consent_Focus Groups PWD_for OMB.docx PWD Consent for Focus Groups	IC Document
2a--DSMES Brand Concept Testing Informed Consent_Survey PWD_for OMB.docx PWD Consent for Online Survey	IC Document
2d-- Brand Concept Testing- PWD Screenshots for OMB .docx PWD Screenshots for Online Survey	IC Document
4a--DSMES Brand Concept Testing Informed Consent_Survey HCP_for OMB.docx HCP Consent for Online Survey	IC Document
4d-Brand Concept Testing- HCP Screenshots for OMB.docx HCP Online Survey Screenshots	IC Document
OMB supplementatl attachment with samples of concepts.docx Attachment with Samples	IC Document
HMTSExpeditedReviewForm_DSMESConcept Testing june222020rev.pdf Expedited Review Form	IC Document
HMTS Expedited Review Supplement-DSMES Brand Cpt Testing for OMB revised re OMB and ICRO comments.docx Supplemental Information	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Brand Concept Testing for Diabetes Self-Management Education and Support (DSMES) Services Marketing Support

Agency IC Tracking Number:

0920-0572-20PB

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	PWD Screener Online Survey	2b--DSMES Brand Concept Testing_PWD Screener Survey_for OMB.docx	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0572	PWD Online Survey	2c--DSMES Brand Concept Testing PWD Survey_for OMB.docx	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0572	HCP Screener In Depth Interview	3a--DSMES Brand Concept Testing_HCP Screener IDI for OMB.docx	No		Fillable Fileable
Form and Instruction	0920-0572	HCP In Depth Interview Guide	3b--DSMES Brand Concept Testing - IDI Guide- for OMB.docx	No		Fillable Fileable
Form and Instruction	0920-0572	HCP Screener Online Survey	4b--DSMES Brand Concept Testing_HCP Screener Survey for OMB rev.docx	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0572	HCP Online Survey	4c--DSMES Brand Concept Testing HCP Survey for OMB.docx	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0572	PWD Focus Group Moderators Guide	1c--DSMES Brand Concept Testing - FG Moderators Guide for OMB.docx	No		Fillable Fileable
Form and Instruction	0920-0572	PWD Screener for Focus Groups	1b--DSMES Brand Concept Testing_PWD Screener Focus Groups_for OMB.docx	No		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: 3,144

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 80 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,144	3,144
Annual IC Time Burden (Hours)	477	477
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
PWD Consent for Focus Groups	1a--DSMES Brand Concept Testing Informed Consent_Focus Groups PWD_for OMB.docx	07/10/2020
PWD Consent for Online Survey	2a--DSMES Brand Concept Testing Informed Consent_Survey PWD_for OMB.docx	07/10/2020
PWD Screenshots for Online Survey	2d-- Brand Concept Testing- PWD Screenshots for OMB .docx	07/16/2020
HCP Consent for Online Survey	4a--DSMES Brand Concept Testing Informed Consent_Survey HCP_for OMB.docx	07/10/2020
HCP Online Survey Screenshots	4d-Brand Concept Testing- HCP Screenshots for OMB.docx	07/10/2020
Attachment with Samples	OMB supplementatl attachment with samples of concepts.docx	07/10/2020
Expedited Review Form	HMTSExpeditedReviewForm_DSMESConcept Testing june222020rev.pdf	07/10/2020
Supplemental Information	HMTS Expedited Review Supplement-DSMES Brand Cpt Testing for OMB revised re OMB and ICRO comments.docx	07/10/2020

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