Information Collection

Tick- and Mosquito-borne Disease Prevention Message Evaluation

IC 251679 under ICR 202108-0920-006 · OMB 0920-0572.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0572 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0572 Tick- and Mosquito-borne Disease Prevention Message Evaluation	Form and Instruction
0920-0572 Focus Group Screening Form Att. 2- Focus Group Screening Form .docx	Form and Instruction
0920-0572 Focus Group Invitation Att. 3- Focus Group Invitation Text.docx	Form and Instruction
0920-0572 Focus Group Discussion Guide Att 4- Focus Group Guide and Consent Form .docx	Form and Instruction
Att. 1- Focus Group Recruitment Text .docx Recruitment Script	IC Document
Att. 5- Resources to Learn About Tick- _ Mosquito-borne Diseases.docx List of messages to be tested - Resources to Learn About Tick- & Mosquito-borne Diseases	IC Document
DVBD OMB HMTS Expedited Review Form_v4.docx HMTS 0920-0572 Expedited Review Form	IC Document

IC Title:

Tick- and Mosquito-borne Disease Prevention Message Evaluation

Agency IC Tracking Number:

0920-0572-22CY

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

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
Form and Instruction	0920-0572	Focus Group Screening Form	Att. 2- Focus Group Screening Form .docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0572	Focus Group Invitation	Att. 3- Focus Group Invitation Text.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0572	Focus Group Discussion Guide	Att 4- Focus Group Guide and Consent Form .docx	NA	No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 180

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 7 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	180	180
Annual IC Time Burden (Hours)	97	97
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Recruitment Script	Att. 1- Focus Group Recruitment Text .docx	02/18/2022
List of messages to be tested - Resources to Learn About Tick- & Mosquito-borne Diseases	Att. 5- Resources to Learn About Tick- _ Mosquito-borne Diseases.docx	02/18/2022
HMTS 0920-0572 Expedited Review Form	DVBD OMB HMTS Expedited Review Form_v4.docx	02/18/2022

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