View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	Sepsis Campaign Development: Round 2 Concept/Materials Testing for Consumers	Agency IC Tracking Number:	0920-17ANT

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	n/a	Screenshots of the Sepsis R2 Survey for Consumers	B.R2 Sepsis Consumer Survey Screenshots.pdf		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 198	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	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	198	0	198	0	0	0
Annual IC Time Burden (Hours)	24	0	24	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
HMTS Form - Sepsis R2 Testing wtih Consumers	Sepsis R2_HMTSExpeditedReviewForm_v4 - Consumers.pdf	06/05/2017
Project Description - Sepsis R2 Testing with Consumers	Sepsis R2 Project Description_5.31.2017 - Consumers.docx	06/05/2017
Test Item C1. Visual with Slogan_A	C1.Visual with slogan_A.png	06/05/2017
Test Item C2. Visual with Slogan_B	C2.Visual with slogan_B.png	06/05/2017
Test Item C3. Visual with Slogan_C	C3.Visual with slogan_C.png	06/05/2017
Test Item C4. Visual with Slogan_D	C4.Visual with slogan_D.png	06/05/2017
Test Item C5. Visual with Slogan_E	C5.Visual with slogan_E.png	06/05/2017
Test Item C6. Print Concept_A	C6.Sepsis_Print_Concept_A.pdf	06/05/2017
Test Item C7. Print Concept_B	C7.Sepsis_Print_Concept_B.pdf	06/05/2017
Test Item C8. Print Concept_C	C8.Sepsis_Print_Concept_C.pdf	06/05/2017
Test Item C9. Campaign Stimuls_TV Ads	C9.Sepsis Campaign Stimulus_TV Ads.docx	06/05/2017
Test Item C11. Consumer Definition_Sepsis	C11.CONSUMER Sepsis definition_ R2 testing_FINAL.docx	06/05/2017

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