OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Ethnicity & Race: Messaging to Improve Patient-Provider Communication and Engagement on Risks of Alcohol Use During Pregnancy

IC 235993 under ICR 201610-0920-009 · OMB 0920-1154.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form 0920-1154
Consent Form Provider (Online Survey) Ethnicity & Race: Messaging to Improve Patient-Provider Communication and Engagement on Risks of Alcohol Use During Pregnancy		 Form and Instruction
Form 0920-1154
Consent Form Provider In-Depth Interview Ethnicity & Race: Messaging to Improve Patient-Provider Communication and Engagement on Risks of Alcohol Use During Pregnancy		 Form and Instruction
Form 0920-1154
Consent Form Women In-Depth Interview Ethnicity & Race: Messaging to Improve Patient-Provider Communication and Engagement on Risks of Alcohol Use During Pregnancy		 Form and Instruction
Form 0920-1154
Provider Screener and Online Survey Ethnicity & Race: Messaging to Improve Patient-Provider Communication and Engagement on Risks of Alcohol Use During Pregnancy		 Form
Attachment E_ Provider Online Survey Screenshots.pdf Other-Screenshots
Attachment F_Provider IDI Guide_all_instruments_combined.docx Other-WORD
Attachment G_CDC FASD recruitment communications_1May2019_clean.docx Instruction
Attachment H_Women_IDI_Screener_1May2019_clean.docx Other-WORD
Attachment I FASD Screener for Women of Reproductive Age Screenshots.pdf Other-Screenshots
Attachment J_Landing page screenshot.png Other-Screenshots
0920-1154 Consent Form Provider (Online Survey)
Attachment A_ConsentForm_ProviderSurvey_Mar2019.docx 		Form and Instruction
0920-1154 Consent Form Provider In-Depth Interview
Attachment B_ConsentForm_ProviderIDI_Mar2019.docx 		Form and Instruction
0920-1154 Consent Form Women In-Depth Interview
Attachment C_ConsentForm_WomenIDI.docx 		Form and Instruction
0920-1154 Provider Screener and Online Survey
Attachment D_Provider Screener and Online Survey.docx 		Form
Attachment L_IRB_Approval_Letter.pdf
Att L_IRB		IC Document
Supporting Statement A_03_21_19.docx
Supporting Statement A		IC Document
Supporting Statement B_03_21_19.docx
Supporting Statement B		IC Document
GenICRequestTemplate_AIR_052418.docx
Request for Approval		IC Document

Information Collection (IC) Details

View Information Collection (IC)

layout table

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 0920-1154 Yes Yes Fillable Fileable
Form and Instruction 0920-1154 No   Paper Only
Form and Instruction 0920-1154 No   Fillable Fileable Signable
Form 0920-1154 Yes Yes Fillable Fileable
Other-Screenshots No   Paper Only
Other-WORD No   Paper Only
Instruction Yes No Printable Only
Other-WORD No   Printable Only
Other-Screenshots No   Paper Only
Other-Screenshots No   Printable Only

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 900 0 900 0 0 0
Annual IC Time Burden (Hours) 307 0 307 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
Att L_IRB 05/07/2019
Supporting Statement A 05/07/2019
Supporting Statement B 05/07/2019
Request for Approval 05/07/2019
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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