Information Collection

Individual interviews to solicit feedback on Spanish language family-focused materials developed for a pediatric palliative care communications campaign

IC 219062 under ICR 201503-0925-004 · OMB 0925-0653.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0653 can be found here:

2018-05-23 - Reinstatement without change of a previously approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Individual interviews to solicit feedback on Spanish language family-focused materials developed for a pediatric palliative care communications campaign	Form and Instruction
1 Appendic C Interview Script and Questions AppendixC_InterviewInstrumentsSPA.docx	Form and Instruction
2 Appendix A RecruitmentPlan&ScreenerSPA AppendixA_RecruitmentPlan&ScreenerSPA.docx	Form and Instruction
AppendixB_InterviewConsentSPA.docx Appendix B Interview ConsentSPA	IC Document
AppendixD_AtaGlanceSPA.pdf Appendix D_AtaGlanceSPA	IC Document
AppendixE_FindingSupportSPA.pdf AppendixE_Finding SupportSPA	IC Document
AppendixF_FamilyStoriesSPA.pdf AppendixF_FamilyStoriesSPA	IC Document
AppendixG_NoticeofOMBAction.pdf AppendixG_NoticeofOMBAction	IC Document
NINR_0925-0653_FastTrackClearanceSPA.docx NINR Fast Track Clearance SPA	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Individual interviews to solicit feedback on Spanish language family-focused materials developed for a pediatric palliative care communications campaign

Agency IC Tracking Number:

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	1	Appendic C Interview Script and Questions	AppendixC_InterviewInstrumentsSPA.docx		No		Fillable Fileable
Form and Instruction	2	Appendix A RecruitmentPlan&ScreenerSPA	AppendixA_RecruitmentPlan&ScreenerSPA.docx		No		Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 36

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	36	36
Annual IC Time Burden (Hours)	16	16
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Appendix B Interview ConsentSPA	AppendixB_InterviewConsentSPA.docx	11/23/2015
Appendix D_AtaGlanceSPA	AppendixD_AtaGlanceSPA.pdf	11/23/2015
AppendixE_Finding SupportSPA	AppendixE_FindingSupportSPA.pdf	11/23/2015
AppendixF_FamilyStoriesSPA	AppendixF_FamilyStoriesSPA.pdf	11/23/2015
AppendixG_NoticeofOMBAction	AppendixG_NoticeofOMBAction.pdf	11/23/2015
NINR Fast Track Clearance SPA	NINR_0925-0653_FastTrackClearanceSPA.docx	11/23/2015

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