Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
CleverCap App Setup Modified 134 23 0 Form and Instruction n/a Att 4e_CleverCap App Setup English
Form and Instruction n/a Att 4e_CleverCap App Setup Spanish
Instruction
Clinic Assessment Every Six Months Unchanged 8 12 0 Form and Instruction 0920-22FZ Att 4m_Clinic Assessment Every 6 Months
Clinical Assesment Baseline & Final Unchanged 4 8 0 Form and Instruction 0920-22FZ Att 4l_Clinic Assessment Baseline and Final
Patient Baseline Modified 134 101 0 Form and Instruction n/a Att 4c_Patient Baseline Assessment English.docx
Form and Instruction n/a Att 4c_Patient Baseline Assessment Spanish
Form and Instruction 0920-1428 Patient Baseline Assessment-English_02OCT2025
Form and Instruction 0920-1428 Patient Baseline Assessment-Spanish_02OCT2025
Patient Interview Guide Unchanged 10 15 0 Form and Instruction 0920-22FZ Att 4f_Patient Interiew Guide English.docx
Form and Instruction 0920-22FZ Att 4f_Patient Interiew Guide Spanish
Patient Locator Form Modified 134 23 0 Form and Instruction 0920-22FZ Patient Locator Form _English
Form and Instruction 0920-22FZ Att 4b_Patient Locator Form Spanish
Form and Instruction 0920-1428 Patient Locator Form-English_02OCT2025
Form and Instruction 0920-1428 Patient Locator Form-Spanish_02OCT2025
Patient Quarterly Assessment Modified 402 302 0 Form and Instruction n/a Att 4d_Patient Quarterly Assessment English
Form and Instruction n/a Att 4d_Patient Quarterly Assessment Spanish
Form and Instruction 0920-1428 Patient Quarterly Assessment-English_02OCT2025
Form and Instruction 0920-1428 Patient Quarterly Assessment-Spanish_02OCT2025
Patient Screener (English/Spanish) Modified 267 45 0 Form 0920-25AJ Patient Screener (English)
Form 0920-25AJ Patient Screener (Spanish)
Form and Instruction 0920-1428 Patient Screener-English_02OCT2025
Form and Instruction 0920-1428 Patient Screener-Spanish_02OCT2025
Provider Interview Unchanged 7 7 0 Form and Instruction 0920-22FZ Att 4k_Provider Interview Guide
Provider Locator Form Unchanged 7 2 0 Form and Instruction 0920-22FZ Att 4h_Provider Locator Form
Provider Post-Training Assessment Modified 7 4 0 Form and Instruction 0920-22FZ Att 4j_Provider Post-Training Assessment
Form and Instruction 0920-1428 Provider Post-Training Assessment_02OCT2025
Provider Pre-Training Assessment Modified 7 4 0 Form and Instruction n/a Att 4i_Provider Pre-Training Assessment
Form and Instruction 0920-1428 Provider Pre-Training Assessment_02OCT2025
Provider Screening Unchanged 14 3 0 Form and Instruction 0920-22FZ Att 4g_Provider Screener
Total burden requested under this ICR: 1135 549 0  
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