Form 6 Custom Web Survey with Consumer and Provider Paths

Federal COVID Response - Audience Feedback to Inform Ongoing Messaging and Strategies for "Combat COVID" (OD)

Attachment 6 - Custom Web Survey with Consumer and Provider Paths 060221

Benchmark & Follow-Up Web Surveys – Consumer Audience

OMB: 0925-0769

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0925-0769 can be found here:

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Welcome Screen

dmConsent

Public reporting burden for this collection of information is estimated to average 15 minutes per response,

including the time for reviewing instructions, searching existing data sources, gathering and maintaining the

data needed, and completing and reviewing the collection of information. An Agency may not conduct or

sponsor, and a person is not required to respond to, a collection of information unless it displays a current

valid OMB control number. Send comments regarding this burden estimate or any other aspect of this

collection of information, including suggestions for reducing this burden, to NIH, Project clearance

Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (XXXX-XXXX). Do

not return the completed form to this address.

dmCntry

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OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

dmGen & dmAge

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OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

dmHispUS

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OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

dmRaceMUS

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OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

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OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

dmEmploy

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OMB Control Number: XXXX-XXXX Expiration Date: XX/XX/XXXX

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OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

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OMB Control Number: XXXX-XXXX Expiration Date: XX/XX/XXXX

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OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

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OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

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OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

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OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

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OMB Control Number: XXXX-XXXX

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OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

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OMB Control Number: XXXX-XXXX

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OMB Control Number: XXXX-XXXX Expiration Date: XX/XX/XXXX

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OMB Control Number: XXXX-XXXX

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OMB Control Number: XXXX-XXXX

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OMB Control Number: XXXX-XXXX

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OMB Control Number: XXXX-XXXX

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OMB Control Number: XXXX-XXXX

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OMB Control Number: XXXX-XXXX

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OMB Control Number: XXXX-XXXX

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OMB Control Number: XXXX-XXXX

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OMB Control Number: XXXX-XXXX

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OMB Control Number: XXXX-XXXX

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OMB Control Number: XXXX-XXXX

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OMB Control Number: XXXX-XXXX

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OMB Control Number: XXXX-XXXX

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OMB Control Number: XXXX-XXXX

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OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

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OMB Control Number: XXXX-XXXX Expiration Date: XX/XX/XXXX

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OMB Control Number: XXXX-XXXX

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OMB Control Number: XXXX-XXXX

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OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Real Answer Check

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OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

ISQ Check

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OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

dmStateUS

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OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

dmZipUS

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OMB Control Number: XXXX-XXXX

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OMB Control Number: XXXX-XXXX

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dmEduUS

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OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

dmMarStat

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OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

dmAdultHh

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OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

dmChildHh

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OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

dmHhIncUS

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OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Andrew Walton
File Modified	0000-00-00
File Created	2021-06-04