Information Collection

Intake and 6-Month Follow-up

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

Documents and Forms

Documents and forms in this information collection
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

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.