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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Focus Groups Assessing the Uptake and Effectiveness of Inside Knowledge: Get the Facts About Gynecologic Cancer Campaign Materials
Agency IC Tracking Number:
16HS
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
NA
Recruitment Form - Hispanic
D1_Recruitment Form His.doc
NA
Yes
Yes
Fillable Fileable
Form and Instruction
NA
Recruitment Form -Low SES
D2_Recruitment Form lowSES.doc
NA
Yes
Yes
Fillable Fileable
Form and Instruction
NA
Recruitment Form - Disabilities
D3_Recruitment Form disabilities.doc
NA
Yes
Yes
Fillable Fileable
Instruction
C_Focus Group Guide_121815.docx
NA
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Illness Prevention
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
582
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
5 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
582
0
582
0
0
0
Annual IC Time Burden (Hours)
402
0
402
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Supporting Statement A
SSA_IK GenIC_122215.doc
12/29/2015
Supporting Statement B
SSB_IK GenIC_122215.doc
12/29/2015
Consent Form
App B_Consent.doc
12/29/2015
Inside Knowledge - Cervical Cancer Facts
E1_cervical_facts.pdf
12/29/2015
Inside Knowledge - Uterine Cancer Facts
E2_uterine_facts.pdf
12/29/2015
Inside Knowledge - Ovarian Cancer Facts
E3_ovarian_facts.pdf
12/29/2015
Inside Knowledge - Vaginal and Vulvar Cancer Facts
E4_vagvulv_facts.pdf
12/29/2015
PHSA
App A1_PHSA.docx
12/29/2015
Johanna's Law
App A2_Johannas Law.pdf
12/29/2015
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.