Information Collection

Bundled Sub-Studies #20 (Concise ICD), #21 (Accrual CT), and #22 (Spanish Consent)

IC 201931 under ICR 201008-0925-004 · OMB 0925-0046.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0046 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Bundled Sub-Studies #20 (Concise ICD), #21 (Accrual CT), and #22 (Spanish Consent) Form and Instruction
1 Screener ICD #20_Attach 20B_Screener_ICD.pdf Form and Instruction
2 Survey Screenshots ICD #20_Attach 20C_Survey_ICD.pdf Form and Instruction
3 Oncology Survey Screenshots Accrual CT #21_Attach 21A Oncology Survey_AccrualCT.pdf Form and Instruction
4 Staff Survey Screenshots Accrual CT #21_Attach 21B Staff Survey_AccrualCT.pdf Form and Instruction
5 Concept Survey Screenshots Accrual CT #21_Attach 21C Concept Survey_AccrualCT.pdf Form and Instruction
6 Prospective Survey Screenshots Accrual CT #21_Attach 21D Prospective template_AccrualCT.pdf Form and Instruction
7 Screener Spanish Consent #22_Attach_22A_Consent_Screener.doc Form and Instruction
8 English Interview Guide - Spanish Consent #22_Attach_22B_Consent_Interview Guide-ENGLISH.doc Form and Instruction
9 Spanish Interview Guide - Spanish Consent #22_Attach_22C_Consent_Interview Guide-SPANISH.doc Form and Instruction
Memo to OMB_Key To Bundle #20_#21_#22.doc Memo Guide IC Document
Bundle Gen IC Form_20-21-22_ICD_Accrual CT Rev_Consent.docx Gen IC Forms IC Document
#20_Justif Memo & Attach 20A and 20D_ICD.docx ICD Justif Memo_Email and Education Materials IC Document
#21_Justif Memo & Attach 21E and 21F_Accrual CT.docx Accrual CT Justif Memo_Email IC Document
#22_Attach_22D_Sample Consent_SPANISH.doc Spanish Consent_Sample Spanish Consent IC Document
#22_Attach_22E_Sample Consent_ENGLISH.doc Spanish Consent - Sample English Consent IC Document
#22_Justif_Memo_Attach_22F_REVISED_Consent__4-19-12.doc #22_Justif memo & Attach_22F_REVISED_Consent IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Bundled Sub-Studies #20 (Concise ICD), #21 (Accrual CT), and #22 (Spanish Consent)	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Screener ICD	#20_Attach 20B_Screener_ICD.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	2	Survey Screenshots ICD	#20_Attach 20C_Survey_ICD.pdf	No	No	Fillable Fileable
Form and Instruction	3	Oncology Survey Screenshots Accrual CT	#21_Attach 21A Oncology Survey_AccrualCT.pdf	No	No	Fillable Fileable
Form and Instruction	4	Staff Survey Screenshots Accrual CT	#21_Attach 21B Staff Survey_AccrualCT.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	5	Concept Survey Screenshots Accrual CT	#21_Attach 21C Concept Survey_AccrualCT.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	6	Prospective Survey Screenshots Accrual CT	#21_Attach 21D Prospective template_AccrualCT.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	7	Screener Spanish Consent	#22_Attach_22A_Consent_Screener.doc	No	No	Printable Only
Form and Instruction	8	English Interview Guide - Spanish Consent	#22_Attach_22B_Consent_Interview Guide-ENGLISH.doc	No	No	Printable Only
Form and Instruction	9	Spanish Interview Guide - Spanish Consent	#22_Attach_22C_Consent_Interview Guide-SPANISH.doc	No	No	Printable Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 450	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 95 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	450	0	0	0	0	0
Annual IC Time Burden (Hours)	232	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Memo Guide	Memo to OMB_Key To Bundle #20_#21_#22.doc	03/29/2012
Gen IC Forms	Bundle Gen IC Form_20-21-22_ICD_Accrual CT Rev_Consent.docx	03/29/2012
ICD Justif Memo_Email and Education Materials	#20_Justif Memo & Attach 20A and 20D_ICD.docx	03/29/2012
Accrual CT Justif Memo_Email	#21_Justif Memo & Attach 21E and 21F_Accrual CT.docx	03/29/2012
Spanish Consent_Sample Spanish Consent	#22_Attach_22D_Sample Consent_SPANISH.doc	03/29/2012
Spanish Consent - Sample English Consent	#22_Attach_22E_Sample Consent_ENGLISH.doc	03/29/2012
#22_Justif memo & Attach_22F_REVISED_Consent	#22_Justif_Memo_Attach_22F_REVISED_Consent__4-19-12.doc	04/20/2012

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.