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
Form and Instruction n/a
Instruction
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 Modified 134 101 0 Form and Instruction n/a
Form and Instruction n/a
Form and Instruction 0920-1428
Form and Instruction 0920-1428
Patient Interview Guide Unchanged 10 15 0 Form and Instruction 0920-22FZ
Form and Instruction 0920-22FZ
Patient Locator Form Modified 134 23 0 Form and Instruction 0920-22FZ
Form and Instruction 0920-22FZ
Form and Instruction 0920-1428
Form and Instruction 0920-1428
Patient Quarterly Assessment Modified 402 302 0 Form and Instruction n/a
Form and Instruction n/a
Form and Instruction 0920-1428
Form and Instruction 0920-1428
Patient Screener (English/Spanish) Modified 267 45 0 Form 0920-25AJ
Form 0920-25AJ
Form and Instruction 0920-1428
Form and Instruction 0920-1428
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 Modified 7 4 0 Form and Instruction 0920-22FZ
Form and Instruction 0920-1428
Provider Pre-Training Assessment Modified 7 4 0 Form and Instruction n/a
Form and Instruction 0920-1428
Provider Screening Unchanged 14 3 0 Form and Instruction 0920-22FZ
Total burden requested under this ICR: 1135 549 0  
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