Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
CleverCap App Setup New 134 23 0 Form and Instruction 0920-22FZ
Form and Instruction 0920-22FZ
Clinic Assessment Every Six Months New 8 12 0 Form and Instruction 0920-22FZ
Clinical Assesment Baseline & Final New 4 8 0 Form and Instruction 0920-22FZ
Patient Baseline New 134 101 0 Form and Instruction 0920-22FZ
Form and Instruction 0920-22FZ
Patient Interview Guide New 10 15 0 Form and Instruction 0920-22FZ
Form and Instruction 0920-22FZ
Patient Locator Form New 134 23 0 Form and Instruction 0920-22FZ
Form and Instruction 0920-22FZ
Patient Quarterly Assessment New 402 302 0 Form and Instruction 0920-22FZ
Form and Instruction 0920-22FZ
Patient Screener (English/Spanish) New 267 45 0 Form and Instruction 0920-22FZ
Form and Instruction 0920-22FZ
Provider Interview New 7 7 0 Form and Instruction 0920-22FZ
Provider Locator Form New 7 2 0 Form and Instruction 0920-22FZ
Provider Post-Training Assessment New 7 4 0 Form and Instruction 0920-22FZ
Provider Pre-Training Assessment New 7 4 0 Form and Instruction 0920-22FZ
Provider Screening New 14 3 0 Form and Instruction 0920-22FZ
Total burden requested under this ICR: 1135 549 0  
To view an IC, click on IC Title