Information Collection

Addressing the Opioid Crisis in Communities of Color

IC 239259 under ICR 201705-0990-002 · OMB 0990-0421.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0421 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
0990-0421 Generic - Attach A _Discussion Guide_Addressing the Opioid Crisis in Communities of Color_FINAL_OMB 03092020.docx	Other-discussion guide
0990-0421 Generic - Attachment B_Small Group Discussion Guide_Addressing the Opioid Crisis in Communities of Color_FINAL_OMB 030	Other-Discussion Guide
0990-0421 Generic Attachment C_Script for Verbal Consent_OUD and communities of color_March 12 2020.docx	Other-Consent form
0990-0421 Generic - CoverSheet_Addressing the Opioid Crisis in Communities of Color_FINAL.docx coversheet	IC Document
0990-0421 Generic - SupportingStatement A_Addressing the Opioid Crisis in Communities of Color_FINAL_OMB 03092020.docx SS-A	IC Document
0990-0421 Generic - SupportingStatement B_Addressing the Opioid Crisis in Communities of Color_FINAL.docx SS-B	IC Document

IC Title:

Addressing the Opioid Crisis in Communities of Color

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Electronic Capability
Other-Consent form	0990-0421 Generic Attachment C_Script for Verbal Consent_OUD and communities of color_March 12 2020.docx	No	Paper Only
Other-discussion guide	0990-0421 Generic - Attach A _Discussion Guide_Addressing the Opioid Crisis in Communities of Color_FINAL_OMB 03092020.docx	No	Paper Only
Other-Discussion Guide	0990-0421 Generic - Attachment B_Small Group Discussion Guide_Addressing the Opioid Crisis in Communities of Color_FINAL_OMB 03092020.docx	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 64

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	64	64
Annual IC Time Burden (Hours)	96	96
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
coversheet	0990-0421 Generic - CoverSheet_Addressing the Opioid Crisis in Communities of Color_FINAL.docx	01/14/2020
SS-A	0990-0421 Generic - SupportingStatement A_Addressing the Opioid Crisis in Communities of Color_FINAL_OMB 03092020.docx	03/13/2020
SS-B	0990-0421 Generic - SupportingStatement B_Addressing the Opioid Crisis in Communities of Color_FINAL.docx	01/14/2020

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