Information Collection

DGA 2020-2025 Survey and Focus Group (English and Spanish)

IC 242953 under ICR 201902-0584-002 · OMB 0584-0523.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Attachment A-1 Screener (English) clean OCIO 081120.docx Other-Attachment A-1 Screener (Engli
Attachment A-2 Discussion Guide (English) clean OCIO 081120.docx Other-Attachment A-2 Discussion Guid
Attachment A-3 Confirmation Form (English) clean OCIO 081120.docx Other-Attachment A-3 Confirmation Fo
Attachment A-4 Consent Form (English).docx Other-Attachment A-4 Consent Form (E
Attachment A-7 Focus Group Public Burden Statement (English).docx Other-Attachment A-7 Focus Group Pub
Attachment A-7a Survey Public Burden Statement (English).docx Other-Attachment A-7a Survey Public
Attachment A-8 Survey Questionnaire (English) clean OCIO 081020.docx Other-Attachment A-8 Survey Question
Attachment A-9 Survey Invitation (English) clean OCIO 081120.docx Other-Attachment A-9 Survey Invitati
Attachment A-10 Survey Screen Shots (English).pptx Other-Attachment A-10 Survey Screen
Attachment C-1 Screener (English) clean OCIO 081020.docx Other-Attachment C-1 Screener (Engli
Attachment C-2 Discussion Guide (English) clean OCIO 081120.docx Other-Attachment C-2 Discussion Guid
Attachment E-1 Screener (English) clean OCIO 081120.docx Other-Attachment E-1 Focus Group Scr
Attachment E-2 Discussion Guide (English) clean OCIO 081120 (v1).docx Other- Attachment E-2 Discussion Gui
B-1 Screener (Spanish) clean OCIO 081120.docx Other-Attachment B-1 Screener (Spani
B-2 Discussion Guide (Spanish) clean OCIO 081120.docx Other-Attachment B-2 Discussion Guid
B-3 Confirmation Form (Spanish) clean OCIO 081120.docx Other-Attachment B-3 Confirmation Fo
B-4 Consent Form (Spanish) clean OCIO 081120.docx Other-Attachment B-4 Consent Form (S
B-7 Focus Group Public Burden Statement (Spanish).docx Other-Attachment B-7 Focus Group Pub
B-7a Survey Public Burden Statement (Spanish).docx Other-Attachment B-7a Survey Public
B-8 Survey Questionnaire (Spanish) clean OCIO 081020.docx Other-Attachment B-8 Survey Question
B-9 Survey Invitation (Spanish) clean OCIO 081120.docx Other-Attachment B-9 Survey Invitati
Attachment B-10 Survey Screen Shots (Spanish).pptx Other-Attachment B-10 Survey Screen
D-1 Screener (Spanish) clean OCIO 081120.docx Other-Attachment D-1 Screener (Spani
D-2 Discussion Guide (Spanish) clean OCIO 081120.docx Other-Attachment D-2 Discussion Guid
Cover Memo_final clean OCIO 081020.docx
DGC 2020-2025 OMB Memo
IC Document
Attachment E-3 Burden Estimates Excel Chart (English).xlsx
Attachement 3 Burden Estimates Excel Chart
IC Document
Attachment A-5 Confidentiality Agreement (English).docx
Attachment A-5 Confidentiality Agreement (English)
IC Document
B-5 Confidentiality Agreement (Spanish).docx
Attachment B-5 Confidentiality Agreement (Spanish)
IC Document
Attachment A-6 Privacy Act Statement (English).docx
Attachment A-6 Privacy Act Statement (English).docx
IC Document
B-6 Privacy Act Statement (Spanish).docx
Attachment B-6 Privacy Act Statement (Spanish)
IC Document

Information Collection (IC) Details

View Information Collection (IC)

layout table

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
Other-Attachment A-1 Screener (English) (Pregnant Women 8-11-2020) www.notyetcreated.com Yes Yes Fillable Fileable Signable
Other-Attachment A-2 Discussion Guide (English) (Pregnant Women 8-11-2020) www.notyetcreated.com Yes Yes Fillable Fileable Signable
Other-Attachment A-3 Confirmation Form for Focus Group Participants (English 8-11-2020) Via email addresses Yes No Fillable Fileable Signable
Other-Attachment A-4 Consent Form (English).docx Via email addresses No   Fillable Fileable Signable
Other-Attachment A-7 Focus Group Public Burden Statement (English).docx www.notyetcreated.com Yes Yes Fillable Fileable Signable
Other-Attachment A-7a Survey Public Burden Statement (English).docx www.notyetcreated.com Yes Yes Fillable Fileable Signable
Other-Attachment A-8 Survey Questionnaire (English 8-10-2020).docx www.notyetcreated.com Yes Yes Fillable Fileable Signable
Other-Attachment A-9 Survey Invitation (English 8-11-2020) www.notyetcreated.com Yes Yes Fillable Fileable Signable
Other-Attachment A-10 Survey Screen Shots (English) www.notyetcreated.com Yes Yes Fillable Fileable Signable
Other-Attachment C-1 Screener (English) (B-24 Caregiver Audience 8-11-2020) www.notyetcreated.com Yes Yes Fillable Fileable Signable
Other-Attachment C-2 Discussion Guide (English) (B-24 Caregiver Audience 8-11-2020) www.notyetcreated.com Yes Yes Fillable Fileable Signable
Other-Attachment E-1 Focus Group Screener (English) (Remaining Consumer Audiences 8-11-2020) www.notyetcreated.com Yes Yes Fillable Fileable Signable
Other- Attachment E-2 Discussion Guide (English) (Remaining Consumer Audiences 8-11-2020) www.notyetcreated.com Yes Yes Fillable Fileable Signable
Other-Attachment B-1 Screener (Spanish) (Pregnant Women) www.notyetcreated.com Yes Yes Fillable Fileable Signable
Other-Attachment B-2 Discussion Guide (Spanish) (Pregnant Women) www.notyetcreated.com Yes Yes Fillable Fileable Signable
Other-Attachment B-3 Confirmation Form for Focus Group Participants (Spanish) Via email address Yes No Fillable Fileable Signable
Other-Attachment B-4 Consent Form (Spanish) via e-mail address No   Fillable Fileable Signable
Other-Attachment B-7 Focus Group Public Burden Statement (Spanish) www.notyetcreated.com Yes Yes Fillable Fileable Signable
Other-Attachment B-7a Survey Public Burden Statement (Spanish) www.notyetcreated.com Yes Yes Fillable Fileable Signable
Other-Attachment B-8 Survey Questionnaire (Spanish) www.notyetcreated.com Yes Yes Fillable Fileable Signable
Other-Attachment B-9 Survey Invitation (Spanish) www.notyetcreated.com Yes Yes Fillable Fileable Signable
Other-Attachment B-10 Survey Screen Shots (Spanish) www.notyetcreated.com Yes Yes Fillable Fileable Signable
Other-Attachment D-1 Screener (Spanish) (B-24 Caregiver Audience) www.notyetcreated.com Yes Yes Fillable Fileable Signable
Other-Attachment D-2 Discussion Guide (Spanish) (B-24 Caregiver Audience) www.notyetcreated.com Yes Yes Fillable Fileable Signable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 29,456 0 29,456 0 0 0
Annual IC Time Burden (Hours) 5,968 0 5,968 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
DGC 2020-2025 OMB Memo 08/10/2020
Attachement 3 Burden Estimates Excel Chart 08/05/2020
Attachment A-5 Confidentiality Agreement (English) 08/07/2020
Attachment B-5 Confidentiality Agreement (Spanish) 08/07/2020
Attachment A-6 Privacy Act Statement (English).docx 08/11/2020
Attachment B-6 Privacy Act Statement (Spanish) 08/11/2020
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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