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Agenda
Reg Review
ICR
Information Collection List
IC Title
Status
Responses
Hours
Dollars
Document Type
Form No.
Form Name
Awardee Recruitment
New
220
440
0
Form
1
Attachment10 National_Awardee and Site Recruitment Materials_final 10_29_2019_psg.docx
Health Center Patient Survey Patient Screening Form
Modified
13120
2230
0
Form
6
National_Patient Arrival and Referral Tracking Form Final_psg.docx
Form
7
Final HCPS Screener_English_09302019_psg.docx
Form
7 C
Final HCPS Screener_Chinese_09302019_psg.docx
Form
7 S
Final HCPS Screener_Spanish_09302019_psg.docx
Form
7 T
Final HCPS Screener_Spanish_09302019_psg.docx
Form
7 V
Final HCPS Screener_Vietnamese_09302019_psg.docx
Form
8
Informed Consent Form for Adult Survey Participation reviewed Final_psg.docx
Form
8 C
Informed Consent Form for Adult Survey Participation Final_TChinese_09272019_clean_psg.docx
Form
8 S
Informed Consent Form for Adult Survey Participation reviewed Final_SPANISH_09-27-2019_psg.docx
Form
8 T
_Informed Consent Form for Adult Survey Participation reviewed Final_SPANISH_09-27-2019_psg.docx
Form
8 V
Informed Consent Form for Adult Survey Participation VIE_09-27-2019_psg.docx
Form
9
Informed Consent Form for Parent or Guardian Proxy reviewed Final_psg.docx
Form
9 C
Informed Consent Form for Parent or Guardian Proxy Final_TChinese_09272019_clean_psg.docx
Form
9 S
Informed Consent Form for Parent or Guardian Proxy reviewed Final_SPANISH_09-27-2019_psg.docx
Form
9 T
Informed Consent Form for Parent or Guardian Proxy Interview for Accompanied Children Tagalog_psg.docx
Form
9 V
Informed Consent Form for Parent or Guardian Proxy VIE_09-27-2019_psg.docx
Form
10
Parent or Guardian Permission form for Accompanied Adolescent reviewed Final_psg.docx
Form
10 S
Parent or Guardian Permission form for Adolescent reviewed Final_SPANISH_09-27-2019_psg.docx
Form
10 T
Parent or Guardian Permission Form for Adolescent Tagalog_psg.docx
Form
10 V
Parent or Guardian Permission form for Adolescent Final VIE_09-27-2019_psg.docx
Form
10 C
Parent or Guardian Permission form for Adolescent Final_TChinese_09272019_clean_psg.docx
Form
11
Assent Form for Accompanied Adolescent reviewed Final_psg.docx
Form
11 C
Assent Form for Accompanied Adolescent Final_TChinese_09272019_clean_psg.docx
Form
11 S
Assent Form for Accompanied Adolescent reviewed Final_SPANISH_09-27-2019_psg.docx
Form
11 V
Assent form for Accompanied Adolescent VIE_09-27-2019_psg.docx
Form
12
Contact Summary Report Form Final_psg.docx
Health Center Patient Survey Patient Survey Instrument
Modified
9000
9000
0
Form
4
Final HCPS Questionnaire_English_09302019_psg.docx
Form
4 C
Final HCPS Questionnaire_Chinese_09302019_psg.docx
Form
4 S
Final HCPS Questionnaire_Spanish_09302019_psg_clean.docx
Form
4 S Tracked Changes
Final HCPS Questionnaire_Spanish_09302019_psg.docx
Form
4 V
Final HCPS Questionnaire_Vietnamese_09302019_psg.docx
Form
4 T
HCPS Questionnaire_Tagalog_09302019_psg.docx
Form
5
Incentive Receipt (English)_psg.docx
Form
5 C
Incentive Receipt_TChinese_psg.docx
Form
5 S
Incentive Receipt_SPA_rev_psg.docx
Form
5 V
Incentive Receipt_Vietnamese_psg.docx
Form
5 T
Incentive Receipt Tagalog_psg.docx
Patient Screening: Short Blessed Scale
New
18
1
0
Form
3
Attachment 13 Short Blessed Scale Test_psg.docx
Form
3 C
Attachment 13 Short Blessed Scale Exam_2019_CH_psg.docx
Form
3 S
Attachment 13 Short Blessed Scale (Spanish)_psg.docx
Form
3 V
Attachment 13 Short Blessed Scale Exam 2019_VIE_psg.docx
Form
3 T
Attachment 13 Short Blessed Scale Exam_Tagalog_psg.docx
Site Recruitment and Training
New
700
2205
0
Form
2
Attachment10 National_Awardee and Site Recruitment Materials_3-23-20
Total burden requested under this ICR:
23058
13876
0
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