Information Collection

Usability Testing of Virtual Reality for Opioid-Sparing Pain Management Among Diverse Patients (OC)

IC 243281 under ICR 201911-0910-015 · OMB 0910-0497.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0910-0497 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Recruitment and Eligbility Screening Script.docx	Other-Screening Script
Consent Form.docx	Other-Consent Form
Interview and Usability Testing Guide for Patients.docx	Other-Testing Guide for Patients
Interview Guide for Healthcare Workers.docx	Other-Interview Guide for HC Workers
Initial Eligibility Screening Email.docx	Other-Initial Eligibility Screening
Health Care Worker Recruitment Email.docx	Other-HC Worker Recruitment Email
Flyer - Invitation to Participate.docx	Other-Flyer - Invitation
0497 OMB Approval Memo for Usability Testing for VR 2020.docx OMB Approval Memo	IC Document
IRB Determination Letter.pdf IRB Letter	IC Document
Terms of clearance.docx Terms of Clearance	IC Document

IC Title:

Usability Testing of Virtual Reality for Opioid-Sparing Pain Management Among Diverse Patients (OC)

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?	Can Be Submitted Electronically?	Electronic Capability
Other-Screening Script	Recruitment and Eligbility Screening Script.docx	Yes	No	Printable Only
Other-Consent Form	Consent Form.docx	Yes	Yes	Fillable Fileable
Other-Testing Guide for Patients	Interview and Usability Testing Guide for Patients.docx	Yes	No	Printable Only
Other-Interview Guide for HC Workers	Interview Guide for Healthcare Workers.docx	Yes	No	Printable Only
Other-Initial Eligibility Screening Email	Initial Eligibility Screening Email.docx	Yes	No	Printable Only
Other-HC Worker Recruitment Email	Health Care Worker Recruitment Email.docx	Yes	No	Printable Only
Other-Flyer - Invitation	Flyer - Invitation to Participate.docx	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
OMB Approval Memo	0497 OMB Approval Memo for Usability Testing for VR 2020.docx	08/24/2020
IRB Letter	IRB Determination Letter.pdf	08/24/2020
Terms of Clearance	Terms of clearance.docx	08/27/2020

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