Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Awardee Recruitment Unchanged 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 T Final HCPS Screener Tagalog_09302019_psg.docx
Form 8 T _Informed Consent Form for Adult Survey Participation reviewed Final Tagalog_09-27-2019_psg.docx
Form 9 T Informed Consent Form for Parent or Guardian Proxy Interview for Accompanied Children Tagalog_psg.docx
Form 10 T Parent or Guardian Permission Form for Adolescent Tagalog_psg.docx
Form 12 Contact Summary Report Form Final_psg.docx
Form 7 2019 HCPS Patient Screener ENGLISH
Form 7 C Final HCPS Screener_Chinese_10-07-2020_For Revisions.docx
Form 7 S Final HCPS Screener_Spanish_10072020
Form 7 V 2019 Patient Screener_Vietnamese_10072020.docx
Form 8 Phone Version_Informed Consent Form for Adult Survey Participation .docx
Form 8 C Phone Version Informed Consent Form for Adult Survey Participation Final_TChinese.docx
Form 8 S Phone Version_Informed Consent Form for Adult Survey Participation reviewed Final_SPANISH_11-04-2020.docx
Form 8 V Phone Version Informed Consent Form for Adult Survey Participation VIE.docx
Form 9 Phone Version_Informed Consent Form for Parent or Guardian Proxy reviewed.docx
Form 9 C Phone Version Informed Consent Form for Parent or Guardian Proxy Final_TChinese.docx
Form 9 S Phone Version_Informed Consent Form for Parent or Guardian Proxy reviewed Final_SPANISH_11-04-2020.docx
Form 9 V Phone Version Informed Consent Form for Parent or Guardian Proxy VIE.docx
Form 10 Phone Version_Parent or Guardian Permission form for Accompanied Adolescent .docx
Form 10 C Phone Version Parent or Guardian Permission form for Adolescent Final_TChinese.docx
Form 10 S Phone_Version_Parent or Guardian Permission form for Adolescent reviewed Final_SPANISH_11-04-2020.docx
Form 10 V Phone Version Parent or Guardian Permission form for Adolescent Final VIE.docx
Form 11 Phone Version_Assent Form for Accompanied Adolescent.docx
Form 11 C Phone Version Assent Form for Accompanied Adolescent Final_TChinese.docx
Form 11 S Phone Version Assent Form for Accompanied Adolescent reviewed Final_SPANISH_11-04-2020_psg.docx
Form 11 V Phone Version Assent form for Accompanied Adolescent VIE.docx
Health Center Patient Survey Patient Survey Instrument Modified 9000 9000 0 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
Form 4 2019 HCPS Questionnaire_ENGLISH
Form 4 C Final HCPS Questionnaire_Chinese_10-07-2020_For Revisions.docx
Form 4 S Final HCPS Questionnaire_Spanish_10072020.docx
Form 4 V 2019 HCPS Questionnaire_Vietnamese_10072020.
Patient Screening: Short Blessed Scale Unchanged 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 Modified 700 2205 0 Form 2 Attachment10 National_Awardee and Site Recruitment Materials_3-23-20
Total burden requested under this ICR: 23058 13876 0  
To view an IC, click on IC Title