Information Collection

Using Peer Mentors to Support PACT Team Efforts to Improve Diabetes

IC 212920 under ICR 201409-2900-005 · OMB 2900-0840.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10-10138 Using Peer Mentors to Support PACT Team Efforts to Improve Diabetes	Form and Instruction
10-10138 Mentoring Instruments - Baseline survey, 6 mo. survey, 1 10-10138 S4 VISN 4 Peer Mentoring Instruments_rev20151001 v2.docx	Form and Instruction
10-10138 Monthly Script Mentor Questions 20151001_V4_PeerMntorDiabetes_MonthlyScriptPeerMentor_8-16-2012 v2.docx	Form and Instruction
10-10138 Qualitative Interview Questions 1-8 20151014_V4_PeerMntorDiab_qualIntrvw_1thru8_7-10-13.doc	Form and Instruction
10-10138 ICF Usual Care Mentee Stage 1 20151014_V4_PeerMntorDiab_ICF_UsualCareMenteeStageI_4-2-2015_clean.doc	Form and Instruction
10-10138 ICF Usual Care Mentee Stage 2 20151014_V4_PeerMntorDiab_ICF_UsualCareMenteeStageII_6-10-2014_Clean.doc	Form and Instruction
10-10138 ICF Mentor 20151014_V4_PeerMntorDiab_ICF_Mentor_6-10-14_Clean.doc	Form and Instruction

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	Available Electronically?	Electronic Capability
Form and Instruction	10-10138	Monthly Script Mentor Questions	20151001_V4_PeerMntorDiabetes_MonthlyScriptPeerMentor_8-16-2012 v2.docx	No	Paper Only
Form and Instruction	10-10138	ICF Mentor	20151014_V4_PeerMntorDiab_ICF_Mentor_6-10-14_Clean.doc	No	Paper Only
Form and Instruction	10-10138	Mentoring Instruments - Baseline survey, 6 mo. survey, 12 mo. survey, 18 mo. survey	10-10138 S4 VISN 4 Peer Mentoring Instruments_rev20151001 v2.docx	No	Paper Only
Form and Instruction	10-10138	ICF Usual Care Mentee Stage 1	20151014_V4_PeerMntorDiab_ICF_UsualCareMenteeStageI_4-2-2015_clean.doc	No	Paper Only
Form and Instruction	10-10138	Qualitative Interview Questions 1-8	20151014_V4_PeerMntorDiab_qualIntrvw_1thru8_7-10-13.doc	No	Paper Only
Form and Instruction	10-10138	ICF Usual Care Mentee Stage 2	20151014_V4_PeerMntorDiab_ICF_UsualCareMenteeStageII_6-10-2014_Clean.doc	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,170

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	5,170	5,170
Annual IC Time Burden (Hours)	1,472	1,472
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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