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Constituent Feedback to Oral Health Education Messages and Materials
Voluntary Partner Surveys to Implement Executive Order 12862 in the Health Resources and Services Administration
OMB: 0915-0212
IC ID: 244935
OMB.report
HHS/HSA
OMB 0915-0212
ICR 202012-0915-001
IC 244935
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0212 can be found here:
2024-01-10 - Revision of a currently approved collection
2024-01-04 - No material or nonsubstantive change to a currently approved collection
Documents and Forms
Document Name
Document Type
Form 1-1 RS
Constituent Feedback to Oral Health Education Messages and Materials
Form
1-1 RS attachment 1 - focus group participant recruitment scree
attachment 1 - focus group participant recruitment screener.docx
Form
1-2 RS attachment 2 - cognitive interview participant recruitme
attachment 2 - cognitive interview participant recruitment screener.docx
Form
1-3 RS attachment 3 - online discussion board participant recru
attachment 3 - online discussion board participant recruitment screener.docx
Form
2-1 EP attachment 4 - focus group evaluation protocols.docx
attachment 4 - focus group evaluation protocols.docx
Form
2-2 EP attachment 5 - cognitive interview evaluation protocols.
attachment 5 - cognitive interview evaluation protocols.docx
Form
2-3 EP attachment 6 - online discussion board evaluation protoc
attachment 6 - online discussion board evaluation protocols.docx
Form
FINALsupporting statement a.docx
Supporting Statement A
IC Document
attachment 7 - brushing and flossing brochure.pdf
attachment 7 - brushing and flossing brochure
IC Document
attachment 8 - dry mouth brochure.pdf
attachment 8 - dry mouth brochure
IC Document
attachment 9 - oral cancer brochure.pdf
attachment 9 - oral cancer brochure
IC Document
attachment 10 - baby's oral health brochure.pdf
attachment 10 - baby's oral health brochure
IC Document
attachment 11 - brushing child's teeth brochure.pdf
attachment 11 - brushing child's teeth brochure
IC Document
attachment 12 - oral health and HIV brochure.pdf
attachment 12 - oral health and HIV brochure
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Constituent Feedback to Oral Health Education Messages and Materials
Agency IC Tracking Number:
IC Status:
New
Obligation to Respond:
Voluntary
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
1-1 RS
attachment 1 - focus group participant recruitment screener.docx
attachment 1 - focus group participant recruitment screener.docx
Yes
Yes
Fillable Fileable
Form
1-2 RS
attachment 2 - cognitive interview participant recruitment screener.docx
attachment 2 - cognitive interview participant recruitment screener.docx
Yes
Yes
Fillable Fileable
Form
1-3 RS
attachment 3 - online discussion board participant recruitment screener.docx
attachment 3 - online discussion board participant recruitment screener.docx
Yes
Yes
Fillable Fileable
Form
2-1 EP
attachment 4 - focus group evaluation protocols.docx
attachment 4 - focus group evaluation protocols.docx
Yes
Yes
Fillable Fileable
Form
2-2 EP
attachment 5 - cognitive interview evaluation protocols.docx
attachment 5 - cognitive interview evaluation protocols.docx
Yes
Yes
Fillable Fileable
Form
2-3 EP
attachment 6 - online discussion board evaluation protocols.docx
attachment 6 - online discussion board evaluation protocols.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Illness Prevention
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
308
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
100 %
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
308
0
308
0
0
0
Annual IC Time Burden (Hours)
182
0
182
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Supporting Statement A
FINALsupporting statement a.docx
12/15/2020
attachment 7 - brushing and flossing brochure
attachment 7 - brushing and flossing brochure.pdf
12/15/2020
attachment 8 - dry mouth brochure
attachment 8 - dry mouth brochure.pdf
12/15/2020
attachment 9 - oral cancer brochure
attachment 9 - oral cancer brochure.pdf
12/15/2020
attachment 10 - baby's oral health brochure
attachment 10 - baby's oral health brochure.pdf
12/15/2020
attachment 11 - brushing child's teeth brochure
attachment 11 - brushing child's teeth brochure.pdf
12/15/2020
attachment 12 - oral health and HIV brochure
attachment 12 - oral health and HIV brochure.pdf
12/15/2020
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.