Information Collection

Patient Focus Group Screener - Small Group Discussion Screener

IC 208618 under ICR 201309-0915-001 · OMB 0915-0371.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Patient Focus Group Screener - Small Group Discussion Screener	Form and Instruction
1 Small Group Discussion Screener AppendixB_SmallGroupDiscussionScreener.docx	Form and Instruction
AppendixA_SmallGroupDiscussionRecruitmentFlyer.pub AppendixA_SmallGroupDiscussionRecruitmentFlyer	IC Document
1 AppendixQ_SmallGroupDiscussionElectronicAd.docx 1 AppendixQ_SmallGroupDiscussionElectronicAd	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
Form and Instruction	1	Small Group Discussion Screener	AppendixB_SmallGroupDiscussionScreener.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 128

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	128	128
Annual IC Time Burden (Hours)	32	32
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
AppendixA_SmallGroupDiscussionRecruitmentFlyer	AppendixA_SmallGroupDiscussionRecruitmentFlyer.pub	08/30/2013
1 AppendixQ_SmallGroupDiscussionElectronicAd	1 AppendixQ_SmallGroupDiscussionElectronicAd.docx	08/30/2013

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