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 Survey – HCP Audience

OMB: 0925-0769

⚠️ Notice: This form may be outdated.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

Document [docx]

Download: docx | pdf

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

Shape3

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

dmGen & dmAge

Shape4

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

dmHispUS

Shape5

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

dmRaceMUS

Shape6

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Shape7

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

dmEmploy

Shape8

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

Q10

Shape9

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Q20

Shape10

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Q30

Shape11

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Q40

Shape12

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Q50

Shape13

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Q60

Shape14

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Q100

Shape15

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Q105

Shape16

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

Q108

Shape17

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Q110

Shape18

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Q111

Shape19

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Q115

Shape20

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Q119

Shape21

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Q120

Shape22

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Q125

Shape23

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Q130

Shape24

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

Q135

Shape25

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Q136

Shape26

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Q137

Shape27

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Q200

Shape28

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Q201

Shape29

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Q202

Shape30

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Q205

Shape31

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Q210

Shape32

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Q215

Shape33

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Q220

Shape34

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Q300

Shape35

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Q305

Shape36

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Q310

Shape37

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Q315

Shape38

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Q320

Shape39

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Q335

Shape40

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Q340

Shape41

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Q405

Shape42

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Q410

Shape43

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

Q415

Shape44

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Q420

Shape45

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Q425

Shape46

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Real Answer Check

Shape47

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

ISQ Check

Shape48

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

dmStateUS

Shape49

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

dmZipUS

Shape50

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

Q330

Shape51

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

dmEduUS

Shape52

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

dmMarStat

Shape53

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

dmAdultHh

Shape54

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

dmChildHh

Shape55

OMB Control Number: XXXX-XXXX

Expiration Date: XX/XX/XXXX

dmHhIncUS

Shape56

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