Barriers to Care Survey

Cooperative Re-Engagement Controlled Trial (CoRECT)

Documents and Forms

Document Name Document Type
Barriers to Care Survey Form and Instruction
MA Barriers to Care Survey Att 5_Mass Barriers to Care Survey.docx Form and Instruction
CT Barriers to Care Survey Att 6_Conn Barriers to Care Survey.docx Form and Instruction
Philadelphia Barriers to Care Survey (modified February Att7_PA Barr_to_care_02102017.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Barriers to Care Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	none	MA Barriers to Care Survey	Att 5_Mass Barriers to Care Survey.docx	Yes	Yes	Fillable Fileable
Form and Instruction	none	CT Barriers to Care Survey	Att 6_Conn Barriers to Care Survey.docx	Yes	Yes	Fillable Fileable
Form and Instruction	none	Philadelphia Barriers to Care Survey (modified February 2017)	Att7_PA Barr_to_care_02102017.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,200	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1,200	1,200
Annual IC Time Burden (Hours)	600	600
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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