Information Collection

Patient Pilot Study Qualitative Interviews - In Depth Interview Guide for Intervention Cases

IC 208622 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 Pilot Study Qualitative Interviews - In Depth Interview Guide for Intervention Cases	Form and Instruction
1 Patient Interview Guide 5 AppendixO_PatientInterviewGuide.docx	Form and Instruction
5 AppendixL_1_CaseConsent.doc 5 AppendixL_1_CaseConsent	IC Document
5 AppendixL_2_ControlConsent.doc 5 AppendixL_2_ControlConsent	IC Document
5 AppendixM_HIPAAAuthorization.doc 5 AppendixM_HIPAAAuthorization	IC Document
AppendixN_PocketCard.docx AppendixN_PocketCard	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	Patient Interview Guide	5 AppendixO_PatientInterviewGuide.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

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	100	100
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
5 AppendixL_1_CaseConsent	5 AppendixL_1_CaseConsent.doc	08/30/2013
5 AppendixL_2_ControlConsent	5 AppendixL_2_ControlConsent.doc	08/30/2013
5 AppendixM_HIPAAAuthorization	5 AppendixM_HIPAAAuthorization.doc	08/30/2013
AppendixN_PocketCard	AppendixN_PocketCard.docx	08/30/2013

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