Information Collection

Raising Public Awareness for Deep Vein Thrombosis/Pulmonary Embolism (DVT/PE)

IC 202588 under ICR 201112-0920-014 · OMB 0920-0919.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0919 can be found here:

2014-10-17 - Revision of a currently approved collection

Documents and Forms

Document Name Document Type
Raising Public Awareness for Deep Vein Thrombosis/Pulmonary Embolism (DVT/PE) Form
Screener Atlanta Male 40-64 Att 2_Screener_2_Atlanta_Hospitalized-male_40-64_corrected 4_12_12.doc Form
Screener Atlanta Female 18-39 Att 1_Screener_1_Atlanta_Hospitalized-female_18-39_corrected4_12_12.doc Form
Screener Atlanta Male 65-80 Att 3_Screener_3_Atlanta_Hospitalized-male_65-80-seniors_corrected 4_12_12.doc Form
Screener Atlanta Female 40-64 Att 4_Screener_4_Atlanta_Hospitalized-female_40-64_corrected 4_12_12.doc Form
Screener Baltimore Female 18-39 Att 5_Screener_5_Baltimore_Hospitalized-female_18-39_corrected 4_12_12.doc Form
Screener Baltimore Male 18-39 Att 6_Screener_6_Baltimore_Hospitalized-male-18-39_corrected 4_12_12.doc Form
Screener Baltimore Female 65-80 Att 7_Screener_7_Baltimore_Hospitalized-female_65-80-seniors_corrected 4_12_12.doc Form
Screener Baltimore Male 40-64 Att 8_Screener_8_Baltimore_Hospitalized-male_40-64_corrected4_12_12.doc Form
Rescreener Att 9_Rescreener_Hospitalized_3 26 12Final.docx Form
Informed Consent Atlanta Att 10_Informed Consent_Atlanta (rev).docx Form
Informed Consent Baltimore Att 12_Informed Consent_Baltimore (rev).docx Form
Focus Group Discussion Guide Att 13_DVT MT Discussion Guide.docx Form
Informed Consent Atlanta-evening Att 11_Informed Consent_Atlanta-evening (rev).docx Form
DVT GenIC Clearance Submission _ option year_3 29_12_amended1.docx Request for Approval IC Document
CDC DVT PPT REV 032612_slideshow.ppt DVT Presentation Slides IC Document
DVT message concepts 3-26-12_FINAL.docx DVT Message Concepts IC Document
DVT-PE Awareness Ads Finalists REV_030912.pdf DVT Awareness Ads IC Document
dvt incentive justificationCS-JB.docx Justification for Incentives IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Raising Public Awareness for Deep Vein Thrombosis/Pulmonary Embolism (DVT/PE)	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Screener Atlanta Male 40-64	Att 2_Screener_2_Atlanta_Hospitalized-male_40-64_corrected 4_12_12.doc	Yes	No	Fillable Fileable
Form	none	Screener Atlanta Female 18-39	Att 1_Screener_1_Atlanta_Hospitalized-female_18-39_corrected4_12_12.doc	Yes	No	Fillable Fileable
Form	none	Screener Atlanta Male 65-80	Att 3_Screener_3_Atlanta_Hospitalized-male_65-80-seniors_corrected 4_12_12.doc	Yes	No	Fillable Fileable
Form	none	Screener Atlanta Female 40-64	Att 4_Screener_4_Atlanta_Hospitalized-female_40-64_corrected 4_12_12.doc	Yes	No	Fillable Fileable
Form	none	Screener Baltimore Female 18-39	Att 5_Screener_5_Baltimore_Hospitalized-female_18-39_corrected 4_12_12.doc	Yes	No	Fillable Fileable
Form	none	Screener Baltimore Male 18-39	Att 6_Screener_6_Baltimore_Hospitalized-male-18-39_corrected 4_12_12.doc	Yes	No	Fillable Fileable
Form	none	Screener Baltimore Female 65-80	Att 7_Screener_7_Baltimore_Hospitalized-female_65-80-seniors_corrected 4_12_12.doc	Yes	No	Fillable Fileable
Form	none	Screener Baltimore Male 40-64	Att 8_Screener_8_Baltimore_Hospitalized-male_40-64_corrected4_12_12.doc	Yes	No	Fillable Fileable
Form	none	Rescreener	Att 9_Rescreener_Hospitalized_3 26 12Final.docx	Yes	No	Fillable Fileable
Form	none	Informed Consent Atlanta	Att 10_Informed Consent_Atlanta (rev).docx	Yes	No	Fillable Printable
Form	none	Informed Consent Baltimore	Att 12_Informed Consent_Baltimore (rev).docx	No	No	Printable Only
Form	none	Focus Group Discussion Guide	Att 13_DVT MT Discussion Guide.docx	Yes	No	Printable Only
Form	none	Informed Consent Atlanta-evening	Att 11_Informed Consent_Atlanta-evening (rev).docx	Yes	No	Printable Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 360	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	360	0	0	0	0	0
Annual IC Time Burden (Hours)	148	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Request for Approval	DVT GenIC Clearance Submission _ option year_3 29_12_amended1.docx	06/04/2012
DVT Presentation Slides	CDC DVT PPT REV 032612_slideshow.ppt	06/04/2012
DVT Message Concepts	DVT message concepts 3-26-12_FINAL.docx	06/04/2012
DVT Awareness Ads	DVT-PE Awareness Ads Finalists REV_030912.pdf	06/04/2012
Justification for Incentives	dvt incentive justificationCS-JB.docx	06/04/2012

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