Information Collection

TALK - Hispanic/Latino Focus Groups

IC 220171 under ICR 201306-0930-003 · OMB 0930-0196.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0196 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Screener TALK - Hispanic/Latino Focus Groups	Form and Instruction
Screener Screener 2016_2_5_UAD SPA PSA Screener_Attachment B.docx	Form and Instruction
Guide Guide 2016_2_5_UAD SPA_Focus Group Guide_Attachment D.docx	Form and Instruction
2016_2_5_UAD SPA_Consent Form_Attachment C.docx Consent Form	IC Document
2016_2_5_OMB Package_UAD SPA_Focus Group.docx Justification	IC Document
TransLet-6doc.doc Transmittal Letter	IC Document
2016_2_5_OMB SPA_Focus Group Protocol_Attachment A.docx Protocol	IC Document

IC Title:

TALK - Hispanic/Latino Focus Groups

Agency IC Tracking Number:

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
Form and Instruction	Screener	Screener	2016_2_5_UAD SPA PSA Screener_Attachment B.docx		Yes	Yes	Fillable Fileable
Form and Instruction	Guide	Guide	2016_2_5_UAD SPA_Focus Group Guide_Attachment D.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 48

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	48	48
Annual IC Time Burden (Hours)	64	64
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Consent Form	2016_2_5_UAD SPA_Consent Form_Attachment C.docx	02/18/2016
Justification	2016_2_5_OMB Package_UAD SPA_Focus Group.docx	02/18/2016
Transmittal Letter	TransLet-6doc.doc	02/18/2016
Protocol	2016_2_5_OMB SPA_Focus Group Protocol_Attachment A.docx	02/18/2016

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