Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Aim 1 Provider Patient Interaction (Baseline and Final) Unchanged 10 5 0 Form and Instruction 0920-22GA Att 4e_Aim1ProviderPatientInteraction
Aim 1 Provider Post-Training Survey Unchanged 10 3 0 Form and Instruction 0920-22GA Att 4d_Aim1ProviderPostTrainingSurvey
Aim 1 Provider Pre- Training Survey Modified 10 3 0 Form and Instruction MOD00003217 Aim 1 Provider Pre-Training Survey
Aim 1 Provider Training Contact Information Unchanged 10 1 0 Form and Instruction 0920-22GA Att 4b_Aim1ProviderTrainingContactInformation
Aim 1 Provider Training Screener Unchanged 20 2 0 Form and Instruction 0920-22GA Att 4a_Aim1ProviderTrainingScreener
Aim 2a Cohort App Setup (English/Spanish) Unchanged 134 67 0 Form and Instruction 0920-22GA Att 4j_Aim2aCohortAppSetupEnglishSpanish
Aim 2a Cohort Baseline Survey (English/Spanish) Unchanged 134 101 0 Form and Instruction 0920-22GA Att 4i_Aim2aCohortBaselineSurveyEnglish
Form and Instruction 0920-22GA Att 4i_Aim2aCohortBaselineSurveySpanish
Aim 2a Cohort Blood Collection Instructions (English/Spanish) Unchanged 134 134 0 Form and Instruction 0920-22GA Att 4l_Aim2a Cohort Blood Collection Instructions English
Aim 2a Cohort Contact Information (English/Spanish) Unchanged 134 11 0 Form and Instruction 0920-22GA Att 4b_Aim1ProviderTrainingContactInformation
Aim 2a Cohort Exit Interview (English/Spanish) Unchanged 15 15 0 Form and Instruction 0920-22GA Att 4m_Aim2a Cohort Exit Interview English
Form and Instruction 0920-22GA Att 4m_Aim2aCohortExitInterviewSpanish
Aim 2a Cohort Follow Up Survey (English/Spanish) Modified 134 302 0 Form and Instruction MOD00003217 Aim 2a Cohort Follow Up Survey English
Form and Instruction 0920-1423-24BY Encuesta de seguimiento de cohortes (Aim2aCohortFollowUpSurveySpanish)
Aim 2a Cohort HIPAA Form (English & Spanish) Unchanged 134 11 0 Form and Instruction 0920-22GA Att 4h_Aim2aCohortHIPAAFormEnglish
Form and Instruction 0920-22GA Att 4h_Aim2aCohortHIPAAFormSpanish
Aim 2a Cohort Screener (English/Spanish) Modified 267 22 0 Form and Instruction MOD00003217 Aim 2a Cohort Screener English
Form and Instruction V2023-1102 Elegibilidad de cohorte (Aim2aCohortScreener_Spanish)
Aim 2b Provider Focus Group Contact Information Unchanged 16 1 0 Form and Instruction 0920-22GA Att 4o_Aim2b Provider FocusGroup Contact Information
Aim 2b Provider Focus Group Guide Unchanged 16 32 0 Form and Instruction 0920-22GA Att 4o_Aim2b Provider FocusGroup Contact Information
Aim 2b Provider Focus Group Screener Unchanged 32 3 0 Form and Instruction 0920-22GA Att_4n_Aim2bProvider FocusGroup Screener
Aim 2b Provider Pre-Focus Group Survey Unchanged 16 1 0 Form and Instruction 0920-22GA Att 4p_Aim2b Provider Pre FocusGroup Survey
Aims 1&2 Clinic Assessment (Baseline & Final) Unchanged 9 18 0 Form and Instruction 0920-22GA Att 4r_Aim1&2ClinicAssessmentBaselineAndFinal
Aims 1&2 Clinic Assessment (every 6 months) Unchanged 9 27 0 Form and Instruction 0920-22GA Aims 1&2 Clinic Assessment (every 6 months)
Total burden requested under this ICR: 1244 759 0  
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