Information Collection

MUH Resident Baseline Survey - Core LA

IC 204443 under ICR 201309-0920-011 · OMB 0920-1004.

Documents and Forms

Document Name Document Type
MUH Resident Baseline Survey - Core LA Form
MUH Resident Baseline - Core - sections A-F clean 12.17.13Att 8A(e)_MUH Resident Baseline Survey.doc Form
MUH Resident Baseline - Core - sections A-F Spanish clean 12.17.13 Att 8A(s)_MUH Resident Baseline Survey_12.15.13.doc Form
clean 12 17. 13 Att 8A-1(s) MUH Resident Adult Participant Consent_9 3 1....docx Consent - LA Adult Spanish IC Document
clean 12.17.13 Att 8A-1(e) MUH Resident Adult Participant Consent_9.3.......docx Consent LA Adult IC Document
Att 8A-2(e) MUHAdult Resident HIPPA form_9.3.13.docx LA IRB Authorization IC Document
Att 8A-2(s) MUHAdult Resident HIPPA form 9.3.13.docx LA IRB Authorization Spanish IC Document
clean 12.17.13 Att 8A-3(e) LA Resident Consent for Child Questions_9.3......docx Consent LA Child IC Document
clean 12 17 13 Att 8A-3(s) LA Resident Consent for Child Questions_9 3 1....docx Consent LA Child Spanish IC Document
clean 12.17.13 Att 8A-4(e)_Resident Recruitment Materials_9.3.13.docx Recruitment Materials IC Document
clean 12 13 13 Att 8A-4(s)_Resident Recruitment Materials_9 3 13.docx Recruitment Materials Spanish IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	MUH Resident Baseline Survey - Core LA	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	MUH Resident Baseline - Core - sections A-F	clean 12.17.13Att 8A(e)_MUH Resident Baseline Survey.doc		Yes	No	Fillable Printable
Form	none	MUH Resident Baseline - Core - sections A-F Spanish	clean 12.17.13 Att 8A(s)_MUH Resident Baseline Survey_12.15.13.doc		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	375	375
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Consent - LA Adult Spanish	clean 12 17. 13 Att 8A-1(s) MUH Resident Adult Participant Consent_9 3 1....docx	12/19/2013
Consent LA Adult	clean 12.17.13 Att 8A-1(e) MUH Resident Adult Participant Consent_9.3.......docx	12/19/2013
LA IRB Authorization	Att 8A-2(e) MUHAdult Resident HIPPA form_9.3.13.docx	09/23/2013
LA IRB Authorization Spanish	Att 8A-2(s) MUHAdult Resident HIPPA form 9.3.13.docx	09/23/2013
Consent LA Child	clean 12.17.13 Att 8A-3(e) LA Resident Consent for Child Questions_9.3......docx	12/19/2013
Consent LA Child Spanish	clean 12 17 13 Att 8A-3(s) LA Resident Consent for Child Questions_9 3 1....docx	12/19/2013
Recruitment Materials	clean 12.17.13 Att 8A-4(e)_Resident Recruitment Materials_9.3.13.docx	12/19/2013
Recruitment Materials Spanish	clean 12 13 13 Att 8A-4(s)_Resident Recruitment Materials_9 3 13.docx	12/19/2013

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