OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Patient Navigator Outreach and Chronic Disease Prevention Demonstration Program

ICR 201112-0915-005 · OMB 0915-0346 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form 14 Quarterly Report Form and Instruction Modified Available
Form 13 Focus_Group_Social_Service Form and Instruction Modified Available
Form 15 Participant Information Form Form and Instruction Modified Available
Form 14 Consent Form Form and Instruction Modified Available
Form 12 Focus_Group_Health_Provider Form and Instruction Modified Available
Form 14 Consent Form Form and Instruction Modified Available
Form 15 Participant Information Form Form and Instruction Modified Available
Form 11 Health_Administrator_Focus_Gorup Form and Instruction Modified Available
Form 15 Participant Information Form Form and Instruction Modified Available
Form 14 Consent Form Form and Instruction Modified Available
Form 10 Cultural Competency Form and Instruction Modified Available
Form 9 Clinic-Wide Measures Form Modified Available
Form 7 Co-Occuring Disorders Form and Instruction Modified Available
Form 8 Clinical Measures Form and Instruction Modified Available
Form 6 PN_Focus Group Form and Instruction Modified Available
Form 15 Participant Information Form Form and Instruction Modified Available
Form 14 Consent Form Form and Instruction Modified Available
Form 5 Target Services Log Form and Instruction Modified Available
Form 4 Forms_20110919.v1 Form and Instruction Modified Available
Form 3 Patient_Navigator_Form Form and Instruction Modified Available
Form 2 VR_12_English_Self20110919v4 Form and Instruction Modified Available
Form 1 IntakeAndTarget_20111014 Form and Instruction Modified Available
Supporting_Statement_Section_BRev11152011.docx Supporting Statement B Uploaded 2011-12-12 Available
Memo_to_OMBNov11_2011.doc Supplementary Document Uploaded 2011-12-12 Available
Patient_Navigator_Outreach_and_Chronic_Disease_Prevention_Demonstration_Program_-_Authorizing_Legislation[.pdf Supplementary Document Uploaded 2011-12-12 Available
Supporting Statement Section Arev 12-12.docx Supporting Statement A Uploaded 2011-12-12 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
198114 Quarterly Report Form and Instruction ModifiedQuarterly Report
198113 Social Service Provider Focus Group Form and Instruction ModifiedFocus_Group_Social_Service
198113 Social Service Provider Focus Group Form and Instruction ModifiedParticipant Information Form
198113 Social Service Provider Focus Group Form and Instruction ModifiedConsent Form
198112 Grantee Health Care Provider Focus Group Form and Instruction ModifiedFocus_Group_Health_Provider
198112 Grantee Health Care Provider Focus Group Form and Instruction ModifiedConsent Form
198112 Grantee Health Care Provider Focus Group Form and Instruction ModifiedParticipant Information Form
198111 Patient Navigator/Health System Administrator Focus Group Form and Instruction ModifiedHealth_Administrator_Focus_Gorup
198111 Patient Navigator/Health System Administrator Focus Group Form and Instruction ModifiedParticipant Information Form
198111 Patient Navigator/Health System Administrator Focus Group Form and Instruction ModifiedConsent Form
198110 Patient Navigator ultural Competency Checklist Form and Instruction ModifiedCultural Competency
198109 Annual Clinic-Wide Clinical Performance Mearsures Report Form ModifiedClinic-Wide Measures
198108 Patient Medical Record and Clini Data Form and Instruction ModifiedCo-Occuring Disorders
198108 Patient Medical Record and Clini Data Form and Instruction ModifiedClinical Measures
198107 Patient Navigator Focus Group Form and Instruction ModifiedPN_Focus Group
198107 Patient Navigator Focus Group Form and Instruction ModifiedParticipant Information Form
198107 Patient Navigator Focus Group Form and Instruction ModifiedConsent Form
198106 Patient Navigator Encounter/Target Services Log Form and Instruction ModifiedTarget Services Log
198106 Patient Navigator Encounter/Target Services Log Form and Instruction ModifiedForms_20110919.v1
198105 Patient Navigator Survey Form and Instruction ModifiedPatient_Navigator_Form
198104 VR-12 Health Status Form Form and Instruction ModifiedVR_12_English_Self20110919v4
198103 Navigated Patient Data Intake Form Form and Instruction ModifiedIntakeAndTarget_20111014

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
01/31/2015 36 Months From Approved
48,583 0 0
11,953 0 0
0 0 0
Reginfo record details
12
table that charts list of burden
IC Title Form No. Form Name
Annual Clinic-Wide Clinical Performance Mearsures Report 9
Grantee Health Care Provider Focus Group 15, 14, 12 ,   ,  
Navigated Patient Data Intake Form 1
Patient Medical Record and Clini Data 8, 7 ,  
Patient Navigator Encounter/Target Services Log 4, 5 ,  
Patient Navigator Focus Group 14, 15, 6 ,   ,  
Patient Navigator Survey 3
Patient Navigator ultural Competency Checklist 10
Patient Navigator/Health System Administrator Focus Group 14, 15, 11 ,   ,  
Quarterly Report 14
Social Service Provider Focus Group 13, 14, 15 ,   ,  
VR-12 Health Status Form 2
table that charts list of burden
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 48,583 0 0 48,583 0 0
Annual Time Burden (Hours) 11,953 0 0 11,953 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Reginfo record details
  No