Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Comparison Group Clinic Director Coordination New 10 80 0 Instruction
Extraction of Grantee Registry/EHR Data New 660 5280 0 Form and Instruction Electronic Data Collection Tool Electronic Data Collection Tool
Focus Groups New 240 240 0 Form and Instruction Electronic Data Collection Tool Electronic Data Collection Tool
Grantee - Site Visits New 110 150 0 Form and Instruction On-site Staff Interview Protocol On-site Staff Interview Protocol
Grantee Director - Phone New 60 60 0 Form and Instruction Telephone Interview Protocol Telephone Interview Protocol
Grantee Director - Web New 149 75 0 Form and Instruction Director Survey Director Survey
Grantee Frontline Staff Survey New 1494 747 0 Form and Instruction Staff Survey Staff Survey
SMI Clients New 4250 4250 0 Form and Instruction Client Health Assessment Questionnaire Client Health Assessment Questionnaire
Total burden requested under this ICR: 6973 10882 0  
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