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[OADC] (genIC) Materials Testing of the MyMobility Plan (MMP) and Associated Materials 0920-0572-24CQ
 
New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form 0920-20572 Screener (24CQ) Attachment_1_Screener.docx Yes Yes Fillable Fileable
Form and Instruction 0920-0572 Consent Form Main Sample (24CQ) Attachment_2a_Consent_Form_Main_Sample.docx Yes Yes Fillable Fileable
Form and Instruction 0920-0572 Consent Form Tribal Sample (24CQ) Attachment_2b_Consent_Form_Tribal_Sample.docx Yes Yes Fillable Fileable
Form and Instruction 0920-0572 Baseline Survey (24CQ) Attachment_3_Baseline_Survey.docx Yes Yes Fillable Fileable
Instruction Attachment_4_Weekly_Invitation_E-mails.docx Yes No Printable Only
Instruction Attachment_5_Weekly_Reminder_E-mails.docx Yes No Printable Only
Form 0920-0572 Weekly Surveys Treatment Group (24CQ) Attachment_6a_Weekly_Surveys_Treatment_Group.docx Yes Yes Fillable Fileable
Form 0920-0572 Weekly Surveys Control Group (24CQ) Attachment_6b_Weekly_Surveys_Control_Group.docx Yes Yes Fillable Fileable
Instruction Attachment_7_Follow-Up_Survey_Emails.docx Yes No Printable Only
Form 0920-0572 Follow-Up Survey (24CQ) Attachment_8_Follow-up_Survey.docx Yes Yes Fillable Fileable
Form 0920-0572 Tribal Survey (24CQ) Attachment_9_Tribal_Survey.docx Yes Yes Fillable Fileable
Instruction Attachment_10_Educational_Materials.pdf No   Printable Only
Form and Instruction 0920-0572 Baseline Survey (24CQ) Edited Attachment_3_Baseline_Survey_edited 3-5-24.docx Yes Yes Fillable Fileable
Form 0920-0572 Tribal Survey (24CQ) Edited Attachment_9_Tribal_Survey_edited 3-5-24.docx Yes Yes Fillable Fileable

Health Public Health Monitoring

 

2,087 0
   
Individuals or Households
 
   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 2,087 0 2,087 0 0 0
Annual IC Time Burden (Hours) 627 0 627 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Health Message Testing System Expedited Review Form (24CQ) HMTSExpeditedReviewForm 2024-01-19.pdf 02/06/2024
Health Message Testing System Expedited Review Form _Extended (24CQ) HMTS_Form_Additional_Information 2024-01-19.docx 02/06/2024
IRB Research Determination (24CQ) Attachment_11_IRB_approval.pdf 02/07/2024
Project Description MyMobility Evaluation (24CQ) Attachment_12_Project_Description.docx 02/07/2024
Authorizing Legislation Attachment_13_Authorizing_Legislation.pdf 02/07/2024
List of Attachments (24CQ) List_of_Attachments.docx 02/07/2024
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.