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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
Document Name
Document Type
Form and Instruction
Other-Screenshots
Other-WORD
Instruction
Other-WORD
Other-Screenshots
Other-Screenshots
Form and Instruction
Form and Instruction
Form and Instruction
Form
IC Document
IC Document
IC Document
IC Document
Information Collection (IC) Details

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Ethnicity & Race: Messaging to Improve Patient-Provider Communication and Engagement on Risks of Alcohol Use During Pregnancy 0920-1154-19AUM
 
New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 0920-1154 Consent Form Provider (Online Survey) Attachment A_ConsentForm_ProviderSurvey_Mar2019.docx Yes Yes Fillable Fileable
Form and Instruction 0920-1154 Consent Form Provider In-Depth Interview Attachment B_ConsentForm_ProviderIDI_Mar2019.docx No   Paper Only
Form and Instruction 0920-1154 Consent Form Women In-Depth Interview Attachment C_ConsentForm_WomenIDI.docx No   Fillable Fileable Signable
Form 0920-1154 Provider Screener and Online Survey Attachment D_Provider Screener and Online Survey.docx Yes Yes Fillable Fileable
Other-Screenshots Attachment E_ Provider Online Survey Screenshots.pdf No   Paper Only
Other-WORD Attachment F_Provider IDI Guide_all_instruments_combined.docx No   Paper Only
Instruction Attachment G_CDC FASD recruitment communications_1May2019_clean.docx Yes No Printable Only
Other-WORD Attachment H_Women_IDI_Screener_1May2019_clean.docx No   Printable Only
Other-Screenshots Attachment I FASD Screener for Women of Reproductive Age Screenshots.pdf No   Paper Only
Other-Screenshots Attachment J_Landing page screenshot.png No   Printable Only

Health Health Care Services

 

900 0
   
Private Sector Businesses or other for-profits
 
   100 %

  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

Title Document Date Uploaded
Att L_IRB Attachment L_IRB_Approval_Letter.pdf 05/07/2019
Supporting Statement A Supporting Statement A_03_21_19.docx 05/07/2019
Supporting Statement B Supporting Statement B_03_21_19.docx 05/07/2019
Request for Approval GenICRequestTemplate_AIR_052418.docx 05/07/2019
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.