Information Collection

Formative Assessment of Barriers to Transition from Adolescent to Adult for Individuals with Congenital Heart Defects

IC 226379 under ICR 201610-0920-009 · OMB 0920-1154.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1154 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Formative Assessment of Barriers to Transition from Adolescent to Adult for Individuals with Congenital Heart Defects	Form
Survey of Parents of Adolescents with Congenital Heart D Att. 1_surveyinstrument_4.13.2017.docx	Form
GenICRequestTemplate_Congenital heart defects_jg_tmj04.12.2017.docx Request for Approval	IC Document
SS_A_CHDtransitionsurvey_4.11.17v3.docx Supporting Statement A	IC Document
SS_B_CHDtransitionsurvey_4.12.17v3.docx Supporting Statement B	IC Document
Att. 2_SupplementalForm1_EmoryTelephoneScript.docx Emory Recruitment Script	IC Document
Att. 3_SupplementalForm2_NYSDOHPreNotificationLetter (003).docx Pre-notification Letter	IC Document
Att. 4_SupplementalForm3_NYSDOHIntroLetter (003).docx Introductory Letter	IC Document
Att. 5_SupplementalForm4_NYSDOHReminderLetter.docx Reminder Letter	IC Document
Att. 6_SupplementalForm5_NYSDOHReminderPostcard (003).docx Reminder Postcard	IC Document
Att.7_SupplementalForm6_NYSDOHThankyouLetter.docx Thank you Letter	IC Document
Att. 8_rpt684_IRB_Form (004).pdf Nonresearch Determination	IC Document

IC Title:

Formative Assessment of Barriers to Transition from Adolescent to Adult for Individuals with Congenital Heart Defects

Agency IC Tracking Number:

17AAA

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	none	Survey of Parents of Adolescents with Congenital Heart Defects	Att. 1_surveyinstrument_4.13.2017.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,100

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 30 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,100	1,100
Annual IC Time Burden (Hours)	367	367
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Request for Approval	GenICRequestTemplate_Congenital heart defects_jg_tmj04.12.2017.docx	04/13/2017
Supporting Statement A	SS_A_CHDtransitionsurvey_4.11.17v3.docx	04/13/2017
Supporting Statement B	SS_B_CHDtransitionsurvey_4.12.17v3.docx	04/13/2017
Emory Recruitment Script	Att. 2_SupplementalForm1_EmoryTelephoneScript.docx	04/13/2017
Pre-notification Letter	Att. 3_SupplementalForm2_NYSDOHPreNotificationLetter (003).docx	04/13/2017
Introductory Letter	Att. 4_SupplementalForm3_NYSDOHIntroLetter (003).docx	04/13/2017
Reminder Letter	Att. 5_SupplementalForm4_NYSDOHReminderLetter.docx	04/13/2017
Reminder Postcard	Att. 6_SupplementalForm5_NYSDOHReminderPostcard (003).docx	04/13/2017
Thank you Letter	Att.7_SupplementalForm6_NYSDOHThankyouLetter.docx	04/13/2017
Nonresearch Determination	Att. 8_rpt684_IRB_Form (004).pdf	04/13/2017

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