Tick- and Mosquito-borne Disease Prevention Message Evaluation

CDC and ATSDR Health Message Testing System

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.