Monthly Outcome Survey (MOS)

ASPA COVID-19 Public Education Campaign Evaluation Surveys

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0475 can be found here:

Documents and Forms

Document Name Document Type
Form Attachment D Monthly Outcome Survey (MOS) Form and Instruction
Attachment D Attachment D: COVID-19 Monthly Outcome Survey – Question Part A_Attachment D_COVID-19 Monthly Outcome Survey_Questionnaire.docx Form and Instruction
Attachment E Attachment E: COVID-19 Monthly Outcome Survey – Ipsos Om Part A_Attachment E_COVID-19 Monthly Outcome Survey_Ipsos Omnibus COVID Questions.docx Form and Instruction
Attachment F Attachment F: COVID-19 Monthly Outcome Survey – Consent Part A_Attachment F_COVID-19 Monthly Outcome Survey_Ipsos Consent Form.docx Form and Instruction
Attachment G Attachment G: COVID-19 Monthly Outcome Survey – Communic Part A_Attachment G_COVID-19 Monthly Outcome Survey_Communications.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Monthly Outcome Survey (MOS)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Attachment D	Attachment D: COVID-19 Monthly Outcome Survey – Questionnaire	Part A_Attachment D_COVID-19 Monthly Outcome Survey_Questionnaire.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Attachment E	Attachment E: COVID-19 Monthly Outcome Survey – Ipsos Omnibus COVID Questions	Part A_Attachment E_COVID-19 Monthly Outcome Survey_Ipsos Omnibus COVID Questions.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Attachment F	Attachment F: COVID-19 Monthly Outcome Survey – Consent Form	Part A_Attachment F_COVID-19 Monthly Outcome Survey_Ipsos Consent Form.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Attachment G	Attachment G: COVID-19 Monthly Outcome Survey – Communications	Part A_Attachment G_COVID-19 Monthly Outcome Survey_Communications.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	60,000	60,000
Annual IC Time Burden (Hours)	10,200	10,200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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