Information Collection

My Family Health Portrait Usability Study

IC 268072 under ICR 202505-0920-006 · OMB 0920-1050.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1050 can be found here:

2025-06-23 - Revision of a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-1050 My Family Health Portrait Usability Study	Form and Instruction
Form 0920-1050 Pre-Study Meeting My Family Health Portrait Usability Study	Form and Instruction
Form 0920-1050 Week 1 Task Questions My Family Health Portrait Usability Study	Form and Instruction
Form 0920-1050 Weeks 2-3 Task Questions My Family Health Portrait Usability Study	Form and Instruction
Form 0920-1050 Weeks 4-5 Task Questions My Family Health Portrait Usability Study	Form and Instruction
Form 0920-1050 Post-Study Interview My Family Health Portrait Usability Study	Form and Instruction
Form 0920-1050 Recruitment Screener My Family Health Portrait Usability Study	Form and Instruction
0920-1050 Pre-Study Meeting Attachment 3_Pre study meeting.docx	Form and Instruction
0920-1050 Pre-Study Meeting Attachment 3_Pre study meeting.docx	Form and Instruction
0920-1050 Week 1 Task Questions Attachment 4a_Week 1_Task_Questions.docx	Form and Instruction
0920-1050 Week 1 Task Questions Attachment 4a_Week 1_Task_Questions.docx	Form and Instruction
0920-1050 Weeks 2-3 Task Questions Attachment 5a_Weeks 2_3 task questions.docx	Form and Instruction
0920-1050 Weeks 2-3 Task Questions Attachment 5a_Weeks 2_3 task questions.docx	Form and Instruction
0920-1050 Weeks 4-5 Task Questions Attachment 6a_Weeks 4_5 task questions.docx	Form and Instruction
0920-1050 Weeks 4-5 Task Questions Attachment 6a_Weeks 4_5 task questions.docx	Form and Instruction
0920-1050 Post-Study Interview Attachment 7_Post study interview.docx	Form and Instruction
0920-1050 Post-Study Interview Attachment 7_Post study interview.docx	Form and Instruction
0920-1050 Recruitment Screener Attachment 1_Recruitment Screener_REVISED.docx	Form and Instruction
0920-1050 Recruitment Screener Attachment 1_Recruitment Screener_REVISED.docx	Form and Instruction
Attachment 4b_Week 1 emails (initial and reminder).docx Week 1 Email Reminder	IC Document
Attachment 4b_Week 1 emails (initial and reminder).docx Week 1 Email Reminder	IC Document
Attachment 5b_Weeks 2_3 emails (weekly and reminder).docx Weeks 2-3 Email Reminder	IC Document
Attachment 5b_Weeks 2_3 emails (weekly and reminder).docx Weeks 2-3 Email Reminder	IC Document
Attachment 6b_Weeks 4_5 emails (weekly and reminder).docx Weeks 4-5 Email Reminder	IC Document
Attachment 6b_Weeks 4_5 emails (weekly and reminder).docx Weeks 4-5 Email Reminder	IC Document
Appendix_A_MFHP Study_Overview.docx MFHP Study Overview	IC Document
Appendix_A_MFHP Study_Overview.docx MFHP Study Overview	IC Document
Appendix_B_MFHP_Screener_Details.docx MFHP Screener Details	IC Document
Appendix_B_MFHP_Screener_Details.docx MFHP Screener Details	IC Document
Attachment 1a_Study Design Graphic.docx MFHP Study Design Graphic	IC Document
Attachment 1a_Study Design Graphic.docx MFHP Study Design Graphic	IC Document
Attachment 2_Consent form.docx MFHP Consent Form	IC Document
Attachment 2_Consent form.docx MFHP Consent Form	IC Document
GenIC Template_MFHP Usability Study.docx 0920-1050 GenIC Request Template	IC Document
GenIC Template_MFHP Usability Study.docx 0920-1050 GenIC Request Template	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

My Family Health Portrait Usability Study

Agency IC Tracking Number:

0920-1050-24GE

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-1050	N/A	Yes	Yes	Fillable Fileable
Form and Instruction	0920-1050	N/A	Yes	Yes	Fillable Fileable
Form and Instruction	0920-1050	N/A	Yes	Yes	Fillable Fileable
Form and Instruction	0920-1050	N/A	Yes	Yes	Fillable Fileable
Form and Instruction	0920-1050	N/A	Yes	Yes	Fillable Fileable
Form and Instruction	0920-1050	N/A	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 160

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	160	160
Annual IC Time Burden (Hours)	137	137
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Week 1 Email Reminder		06/05/2024
Weeks 2-3 Email Reminder		06/05/2024
Weeks 4-5 Email Reminder		06/05/2024
MFHP Study Overview		06/05/2024
MFHP Screener Details		06/05/2024
MFHP Study Design Graphic		06/05/2024
MFHP Consent Form		06/05/2024
0920-1050 GenIC Request Template		06/20/2024

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

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].