Screening for focus group sessions

Campaign Within the Latino Community on Right to Non-Discrimination in Certain Health and Human Service Programs

Documents and Forms

Document Name Document Type
Attachment 2 - Screener for patient caregiver focus group doc 4 24 12 (REV).doc Other-Screener
Attachment 3 - Moderator Guide for focus groups 4 24 12 (REV).docx Attachment 3 - Moderator Guide for focus groups 4 24 12 (REV) IC Document

Information Collection (IC) Details

IC Title:	Screening for focus group sessions	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Screener			Attachment 2 - Screener for patient caregiver focus group doc 4 24 12 (REV).doc		No	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 40	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	4	4
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment 3 - Moderator Guide for focus groups 4 24 12 (REV)	Attachment 3 - Moderator Guide for focus groups 4 24 12 (REV).docx	06/20/2012

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