Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
CleverCap App Setup Unchanged 134 23 0 Form and Instruction n/a
Form and Instruction n/a
Clinic Assessment Every Six Months Unchanged 8 12 0 Form and Instruction 0920-22FZ
Clinical Assesment Baseline & Final Unchanged 4 8 0 Form and Instruction 0920-22FZ
Patient Baseline Unchanged 134 101 0 Form and Instruction n/a
Form and Instruction n/a
Patient Interview Guide Unchanged 10 15 0 Form and Instruction 0920-22FZ
Form and Instruction 0920-22FZ
Patient Locator Form Unchanged 134 23 0 Form and Instruction 0920-22FZ
Form and Instruction 0920-22FZ
Patient Quarterly Assessment Unchanged 402 302 0 Form and Instruction n/a
Form and Instruction n/a
Patient Screener (English/Spanish) Modified 267 45 0 Form 0920-25AJ
Form 0920-25AJ
Provider Interview Unchanged 7 7 0 Form and Instruction 0920-22FZ
Provider Locator Form Unchanged 7 2 0 Form and Instruction 0920-22FZ
Provider Post-Training Assessment Unchanged 7 4 0 Form and Instruction 0920-22FZ
Provider Pre-Training Assessment Unchanged 7 4 0 Form and Instruction n/a
Provider Screening Unchanged 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