Information Collection

Safer Use of Medications During Pregnancy

IC 214220 under ICR 201306-0920-009 · OMB 0920-0990.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Safer Use of Medications During Pregnancy Form and Instruction
Initial Screener for Focus Group Participants
Att 1_Screener - Consumer_Final 14NOV2014.docx
Form and Instruction
Focus Group Consent Form
Att 2a_VFG_Screenshots_Consent Form_All groups REV_18SEP2014.docx
Form and Instruction
Focus Group Screenshot Moderator Guide - Pain
Att 3a_Group 1_VFG_Screen Shots_Pain REV 18SEP2014.docx
Form and Instruction
Focus GroupScreenshot Moderator Guide - Depression
Att 5a_Group 2_VFG_Screen Shots_Depression REV18SEP2014.docx
Form and Instruction
Focus Group Screenshot Moderator Guide - Asthma
Att 7a_Group 3_VFG_Screen Shots_Asthma.docx
Form and Instruction
Focus Group Screenshot Moderator Guide - Previous Pregna
Att 9a_Group 4_VFG Screen Shots_PP Acute Med.docx
Form and Instruction
Focus Group Moderator Guide - Previous Pregnancy Depress
Att 11a_Group 5_VFG Screen Shots_PP Depression.docx
Form and Instruction
Focus Group Screenshot Moderator Guide - Previous Pregna
Att 13a_Group 6_VFG Screen Shots_PP Asthma.docx
Form and Instruction
Follow-Up Interview Moderator Guide - Pain
Att 4_Group 1_Followup Int Guide_Pain REV 18SEP2014.docx
Form and Instruction
Follow-Up Interview Moderator Guide - Depression
Att 6_Group 2_Followup Int Guide_Depression.docx
Form and Instruction
Follow-Up Interview Moderator Guide - Asthma
Att 8_Group 3_Followup Int Guide_Asthma.docx
Form and Instruction
Follow-Up Interview Moderator Guide - Previous Pregnancy
Att 10_Group 4_Followup Int Guide_PP Acute Med.docx
Form and Instruction
Follow-Up Interview Moderator Guide - PreviousPregnancy
Att 12_Group 5_Followup Int Guide_PP Depression.docx
Form and Instruction
Follow-Up Interview Moderator Guide - Previous Pregnancy
Att 14_Group 6_Followup Int Guide_PP Asthma.docx
Form and Instruction
SS A_SaferUseofMedications FINAL 14NOV2014.docx
Supporting Statement A
IC Document
SS B_SaferUseof Medications FINAL 14NOV2014.docx
Supporting Statement B
IC Document
Att 2_VFG_FocusGroup_Consent_8-6-14.docx
Focus Group Consent Form - WORD
IC Document
Att 3_Group 1_VFG_Moderators Guide_Pain.doc
Focus Group Moderator Guide - Pain WORD
IC Document
Att 5_Group 2_VFG_Moderators Guide_Depression.doc
Focus Group Moderator Guide - Depression WORD
IC Document
Att 7_Group 3_VFG_Moderators Guide_Asthma.doc
Focus Group Moderator Guide - Asthma WORD
IC Document
Att 9_Group 4_VFG Moderators Guide_PP Acute Med.doc
Focus Group Moderator Guide - Previous Pregnancy Acute Meds WORD
IC Document
Att 11_Group 5_VFG Moderator's Guide_PP Depression.doc
Focus Group Moderator Guide - Previous Pregnancy Depression WORD
IC Document
Att 13_Group 6_VFG Moderator's Guide_PP Asthma (1).doc
Focus Group Moderator Guide - Previous Pregnancy Asthma WORD
IC Document
Att 15_RTI IRB Approval Notice.13567.Full.pdf
IRB Approval
IC Document
Att 16_VFG Recruitment Email 14NOV2014.docx
VFG Recruitment Email
IC Document

Information Collection (IC) Details

View Information Collection (IC)

layout table

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
Form and Instruction None Initial Screener for Focus Group Participants Att 1_Screener - Consumer_Final 14NOV2014.docx None No   Paper Only
Form and Instruction None Focus Group Consent Form Att 2a_VFG_Screenshots_Consent Form_All groups REV_18SEP2014.docx None Yes Yes Fillable Fileable
Form and Instruction None Focus Group Screenshot Moderator Guide - Pain Att 3a_Group 1_VFG_Screen Shots_Pain REV 18SEP2014.docx None Yes Yes Fillable Fileable
Form and Instruction None Focus GroupScreenshot Moderator Guide - Depression Att 5a_Group 2_VFG_Screen Shots_Depression REV18SEP2014.docx None Yes Yes Fillable Fileable
Form and Instruction None Focus Group Screenshot Moderator Guide - Asthma Att 7a_Group 3_VFG_Screen Shots_Asthma.docx None Yes Yes Fillable Fileable
Form and Instruction None Focus Group Screenshot Moderator Guide - Previous Pregnancy Acute Meds Att 9a_Group 4_VFG Screen Shots_PP Acute Med.docx None Yes Yes Fillable Fileable
Form and Instruction None Focus Group Moderator Guide - Previous Pregnancy Depression Att 11a_Group 5_VFG Screen Shots_PP Depression.docx None Yes Yes Fillable Fileable
Form and Instruction None Focus Group Screenshot Moderator Guide - Previous Pregnancy Asthma Att 13a_Group 6_VFG Screen Shots_PP Asthma.docx None Yes Yes Fillable Fileable
Form and Instruction None Follow-Up Interview Moderator Guide - Pain Att 4_Group 1_Followup Int Guide_Pain REV 18SEP2014.docx None No   Fillable Fileable
Form and Instruction None Follow-Up Interview Moderator Guide - Depression Att 6_Group 2_Followup Int Guide_Depression.docx None No   Fillable Fileable
Form and Instruction None Follow-Up Interview Moderator Guide - Asthma Att 8_Group 3_Followup Int Guide_Asthma.docx None No   Fillable Fileable
Form and Instruction None Follow-Up Interview Moderator Guide - Previous Pregnancy Acute Meds Att 10_Group 4_Followup Int Guide_PP Acute Med.docx None No   Fillable Fileable
Form and Instruction None Follow-Up Interview Moderator Guide - PreviousPregnancy Depression Att 12_Group 5_Followup Int Guide_PP Depression.docx None No   Fillable Fileable
Form and Instruction None Follow-Up Interview Moderator Guide - Previous Pregnancy Asthma Att 14_Group 6_Followup Int Guide_PP Asthma.docx None No   Fillable Fileable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  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 300 0 300 0 0 0
Annual IC Time Burden (Hours) 144 0 144 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
Supporting Statement A SS A_SaferUseofMedications FINAL 14NOV2014.docx 12/11/2014
Supporting Statement B SS B_SaferUseof Medications FINAL 14NOV2014.docx 12/11/2014
Focus Group Consent Form - WORD Att 2_VFG_FocusGroup_Consent_8-6-14.docx 12/11/2014
Focus Group Moderator Guide - Pain WORD Att 3_Group 1_VFG_Moderators Guide_Pain.doc 12/11/2014
Focus Group Moderator Guide - Depression WORD Att 5_Group 2_VFG_Moderators Guide_Depression.doc 12/11/2014
Focus Group Moderator Guide - Asthma WORD Att 7_Group 3_VFG_Moderators Guide_Asthma.doc 12/11/2014
Focus Group Moderator Guide - Previous Pregnancy Acute Meds WORD Att 9_Group 4_VFG Moderators Guide_PP Acute Med.doc 12/11/2014
Focus Group Moderator Guide - Previous Pregnancy Depression WORD Att 11_Group 5_VFG Moderator's Guide_PP Depression.doc 12/11/2014
Focus Group Moderator Guide - Previous Pregnancy Asthma WORD Att 13_Group 6_VFG Moderator's Guide_PP Asthma (1).doc 12/11/2014
IRB Approval Att 15_RTI IRB Approval Notice.13567.Full.pdf 12/11/2014
VFG Recruitment Email Att 16_VFG Recruitment Email 14NOV2014.docx 12/11/2014
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.