Using Peer Mentors to Support PACT Team Efforts to Improve Diabetes

PACT Using Peer Mentors to Support PACT Team Efforts to Improve Diabetes 10-10138

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Using Peer Mentors to Support PACT Team Efforts to Improve Diabetes	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	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 %

	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

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.