Information Collection

Screening for focus group sessions

IC 202817 under ICR 201206-0990-004 · OMB 0990-0401.

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Screener					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 %

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 3 - Moderator Guide for focus groups 4 24 12 (REV)		06/20/2012

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

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