Drexel-cyshcn

CDC/ATSDR Formative Research and Tool Development

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1154 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-1154 DREXEL-CYSHCN Form and Instruction
Attachment D Phone Recruitment Script.docx Instruction
Attachment D Phone Recruitment Script.docx Other-WORD
0920-1154 DREXEL -DEMOGRAPHIC INTAKE FORM PartII - Att F Intake.pdf Form
0920-1154 DISASTER PREPAREDNESS HOME ASSESSMENT SCREENING TOOL Attachment G Drexel Tool (IRB Appendix B).docx Form and Instruction
0920-1154 INTERVIEW GUIDE FOR BRIEF FAMILY INTERVIEW Attachment H Drexel Interview Guide (IRB Appendix C).docx Form
0920-1154 DISASTER PREPAREDNESS HOME ASSESSMENT SCREENING TOOL -- Attachment G Drexel Disaster Prep Tool -- clean_5.22.20.docx Form and Instruction
0920-1154 DISASTER PREPAREDNESS HOME ASSESSMENT SCREENING TOOL -- Attachment G Drexel Disaster Prep Tool -- clean_5.22.20.docx Form and Instruction
GenICRequest_Drexel_CYSHCN_4.20.20.docx Request for Approval IC Document
Attachment A Drexel IRB Modifications Approved Letter.pdf Att A_IRB -Approval of Modifications IC Document
Attachment C Recruitment Flyer.pdf Att C_DREXEL Flyer IC Document
Attachment E Consent (stamped)_English.pdf Att E_DREXEL Consent IC Document
Attachment I Drexel Assent.pdf AttI_Drexel_Assent Form IC Document
SSA_Drexel_CYSHCN_042020.docx SSA IC Document
SSB_Drexel_CYSHCN_4.10.20.docx SSB IC Document
Consent_6.4.20_Revised.docx Att E DREXEL Consent revised IC Document
SSA_Drexel_CYSHCN_DisasterPrep --- clean 7.13.20.docx SSA -- revised IC Document

Information Collection (IC) Details

IC Title:	DREXEL-CYSHCN	Agency IC Tracking Number:	0920-1154-20LV/2

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	0920-1154	DISASTER PREPAREDNESS HOME ASSESSMENT SCREENING TOOL -- revised	Attachment G Drexel Disaster Prep Tool -- clean_5.22.20.docx	No	Fillable Fileable
Form and Instruction	0920-1154	DISASTER PREPAREDNESS HOME ASSESSMENT SCREENING TOOL -- revised	Attachment G Drexel Disaster Prep Tool -- clean_5.22.20.docx	No	Fillable Fileable
Instruction			Attachment D Phone Recruitment Script.docx	No	Paper Only
Other-WORD			Attachment D Phone Recruitment Script.docx	No	Paper Only
Form	0920-1154	DREXEL -DEMOGRAPHIC INTAKE FORM	PartII - Att F Intake.pdf	No	Fillable Fileable
Form and Instruction	0920-1154	DISASTER PREPAREDNESS HOME ASSESSMENT SCREENING TOOL	Attachment G Drexel Tool (IRB Appendix B).docx	No	Fillable Fileable
Form	0920-1154	INTERVIEW GUIDE FOR BRIEF FAMILY INTERVIEW	Attachment H Drexel Interview Guide (IRB Appendix C).docx	No	Paper Only

Line of Business: Disaster Management

Subfunction: Disaster Preparedness and Planning

Privacy Act System of Records
Title:	FR Citation:

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

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	400	400
Annual IC Time Burden (Hours)	878	878
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Request for Approval	GenICRequest_Drexel_CYSHCN_4.20.20.docx	04/20/2020
Att A_IRB -Approval of Modifications	Attachment A Drexel IRB Modifications Approved Letter.pdf	04/16/2020
Att C_DREXEL Flyer	Attachment C Recruitment Flyer.pdf	04/16/2020
Att E_DREXEL Consent	Attachment E Consent (stamped)_English.pdf	04/16/2020
AttI_Drexel_Assent Form	Attachment I Drexel Assent.pdf	04/16/2020
SSA	SSA_Drexel_CYSHCN_042020.docx	04/20/2020
SSB	SSB_Drexel_CYSHCN_4.10.20.docx	04/16/2020
Att E DREXEL Consent revised	Consent_6.4.20_Revised.docx	07/17/2020
SSA -- revised	SSA_Drexel_CYSHCN_DisasterPrep --- clean 7.13.20.docx	07/17/2020

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