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
Aim 1 Provider Post-Training Survey Unchanged 10 3 0 Form and Instruction 0920-22GA
Aim 1 Provider Pre- Training Survey Unchanged 10 3 0 Form and Instruction MOD00003217
Aim 1 Provider Training Contact Information Unchanged 10 1 0 Form and Instruction 0920-22GA
Aim 1 Provider Training Screener Unchanged 20 2 0 Form and Instruction 0920-22GA
Aim 2a Cohort App Setup (English/Spanish) Modified 134 67 0 Form and Instruction 0920-22GA
Form and Instruction 0920-1423
Aim 2a Cohort Baseline Survey (English/Spanish) Modified 134 101 0 Form and Instruction 0920-22GA
Form and Instruction 0920-22GA
Form and Instruction 0920-1423
Form and Instruction 0920-1423
Aim 2a Cohort Blood Collection Instructions (English/Spanish) Unchanged 134 134 0 Form and Instruction 0920-22GA
Form and Instruction 0920-1423
Form and Instruction 0920-1423
Aim 2a Cohort Contact Information (English/Spanish) Unchanged 134 11 0 Form and Instruction 0920-22GA
Aim 2a Cohort Exit Interview (English/Spanish) Modified 15 15 0 Form and Instruction 0920-22GA
Form and Instruction 0920-22GA
Form and Instruction 0920-1423
Form and Instruction 0920-1423
Aim 2a Cohort Follow Up Survey (English/Spanish) Modified 134 302 0 Form and Instruction MOD00003217
Form and Instruction 0920-1423-24BY
Form and Instruction 0920-1423
Form and Instruction 0920-1423
Aim 2a Cohort HIPAA Form (English & Spanish) Unchanged 134 11 0 Form and Instruction 0920-22GA
Form and Instruction 0920-22GA
Aim 2a Cohort Screener (English/Spanish) Modified 267 22 0 Form and Instruction MOD00003217
Form and Instruction V2023-1102
Form and Instruction 0920-1423
Form and Instruction 0920-1423
Form and Instruction 0920-1423
Form and Instruction 0920-1423
Aim 2b Provider Focus Group Contact Information Unchanged 16 1 0 Form and Instruction 0920-22GA
Aim 2b Provider Focus Group Guide Modified 16 32 0 Form and Instruction 0920-22GA
Form and Instruction 0920-1423
Aim 2b Provider Focus Group Screener Unchanged 32 3 0 Form and Instruction 0920-22GA
Aim 2b Provider Pre-Focus Group Survey Modified 16 1 0 Form and Instruction 0920-22GA
Form and Instruction 0920-1423
Form and Instruction 0920-1423
Aims 1&2 Clinic Assessment (Baseline & Final) Unchanged 9 18 0 Form and Instruction 0920-22GA
Aims 1&2 Clinic Assessment (every 6 months) Unchanged 9 27 0 Form and Instruction 0920-22GA
Total burden requested under this ICR: 1244 759 0  
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