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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