Information Collection

Intake and 6-Month Follow-up

IC 210717 under ICR 201403-0930-003 · OMB 0930-0342.

Documents and Forms

Document Name Document Type
Form Recovery Measureme Intake and 6-Month Follow-up Form and Instruction
Recovery Measureme Recovery Measurement Tool OMB Attachment 2 Recovery Measurement Tool.docx Form and Instruction
OMB Attachment 3 - Sample Grantee Invitation Letter.docx Sample Grantee Invitation Letter IC Document
OMB Attachment 4 informed consent.docx informed consent IC Document
OMB Attachment 5 Article.pdf Article IC Document
Attachment 1-IRB.pdf IRB IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Intake and 6-Month Follow-up	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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 and Instruction	Recovery Measurement Tool	Recovery Measurement Tool	OMB Attachment 2 Recovery Measurement Tool.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 150	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	60	60
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Sample Grantee Invitation Letter	OMB Attachment 3 - Sample Grantee Invitation Letter.docx	03/13/2014
informed consent	OMB Attachment 4 informed consent.docx	03/13/2014
Article	OMB Attachment 5 Article.pdf	03/13/2014
IRB	Attachment 1-IRB.pdf	03/13/2014

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