Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Clinic Staff Qualitative Interview Guide New 80 53 0 Form and Instruction NA
Clinic Staff Survey New 80 20 0 Form and Instruction NA
Date of Diagnosis Question New 337 6 0 Form and Instruction NA
Electronic Medical Records (EMR) New 16 256 0 Form and Instruction NA
Non-Research Labor Cost Questionnaire New 4 6 0 Form and Instruction NA
PHC Labor Cost Questionnaire New 4 6 0 Form and Instruction NA
PHC Non-Labor Cost Questionnaire New 48 24 0 Form and Instruction NA
PHC Tailoring Questions New 504 42 0 Form and Instruction NA
Standard of Care Questionnaire New 4 6 0 Form and Instruction NA
Total burden requested under this ICR: 1077 419 0  
To view an IC, click on IC Title