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.

⚠️ Notice: This information collection may be referencing outdated material.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
Form 0920-1154 Ethnicity & Race: Messaging to Improve Patient-Provider Communication and Engagement on Risks of Alcohol Use During Pregnancy	Form and Instruction
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

IC Title:

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

Agency IC Tracking Number:

0920-1154-19AUM

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	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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 900

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	900	900
Annual IC Time Burden (Hours)	307	307
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.