Information Collection

Drexel-cyshcn

IC 241328 under ICR 201912-0920-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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 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

IC Title:

DREXEL-CYSHCN

Agency IC Tracking Number:

0920-1154-20LV/2

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?	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 %

table that charts list of burden
	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

table that charts IC Documents
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.