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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Formative Research to Develop Social Marketing Campaigns: Prevention Is Care (PIC)
Agency IC Tracking Number:
0920-0840-14AXK
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
None
Provider Screening Instrument
Att 4 Provider Screening Instrument.docx
None
No
Paper Only
Form
None
Paper and Pencil Survey
Att 2 Paper and Pencil Survey.docx
None
No
Paper Only
Form
None
Informed Consent Form
Att 6 Informed Consent Forms.docx
None
No
Paper Only
Form and Instruction
None
Provider Screening Instrument
Att 3 Provider Interview Guide.docx
None
No
Paper Only
Form
None
Review Material-Envelope
Att 5.1_Envelope.pdf
None
No
Paper Only
Form
None
Review Material Folder
Att 5.2_Folder.pdf
None
No
Paper Only
Form
None
Review Material Brouchure and Folding Instructions
Att 5.3_BRC & folding instructions.pdf
None
No
Paper Only
Form
None
Review Material Patient Baseline Screen
Att 5.4_Patient Baseline Screener.pdf
None
No
Paper Only
Form
None
Review Material Patient Adherence Brochure
Att 5.5_Patient Adherence Brochure.pdf
None
No
Paper Only
Form
None
Review Material Adherence Wall Poster
Att 5.6_Adherence Wall Poster.pdf
None
No
Paper Only
Form
None
Review Material Risk Reduction MD Brochure
Att 5.7_Risk Reduct MD Brochure.pdf
None
No
Paper Only
Form
None
Review Material Patient Action Plan
Att 5.8_Patient Action Plan.pdf
None
No
Paper Only
Form
None
Review Material Patient Risk Reduction Brochure
Att 5.9_Patient Risk Reduct Brochure.pdf
No
Paper Only
Form
None
Review Material Retention Brochure MD
Att 5.10_Retent MD Brochure.pdf
None
No
Paper Only
Form
None
Review Material Patient Record Form
Att 5.11_Patient Record Form.pdf
None
No
Paper Only
Form
None
Review Material Retention Brochure Patient
Att 5.12_Patient Retent Brochure.pdf
None
No
Paper Only
Form
None
Review Material Retention Poster
Att 5.13_Retent_Poster.pdf
None
No
Paper Only
Form
None
Review Material Gardner Study Reprint
Att 5.14_Gardner Reprint Carrier.pdf
None
No
Paper Only
Form
None
Review Material Adherence Brochure MD
Att 5.15_Adherence MD Brochure.pdf
None
No
Paper Only
Form
None
CME Promotion Card
Att 5.16_CME Promo Card.pdf
None
No
Paper Only
Form
None
Review Material Risk Reduction Poster Option
Att 5.17_Risk Reduct Poster Option.pdf
None
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Public Health Monitoring
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
480
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
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
480
0
480
0
0
0
Annual IC Time Burden (Hours)
154
0
154
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
IRB Approval Letter
Att 7 IRB Approval.pdf
09/24/2014
Reminder Email Letter
Att 8 Reminder Email_Letter.docx
09/24/2014
Supporting Statement B
SSB 02SEP2014.docx
09/24/2014
Privacy Agreement
Att 1 Privacy Agreement.docx
09/24/2014
Supporting Statement A
SSA 07OCT14.doc
10/07/2014
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.