Appendix B1. HSA Interview Guide

Evaluation of Learning Health Systems K12 Training Program

Documents and Forms

Document Name Document Type
Form B1 Appendix B1. HSA Interview Guide Form
B1 Appendix B1. HSA Interview Guide Appendix B1. HSA Discussion Guide_5-18-20.docx Form
Appendix B2. HSA Invitation Email.docx Appendix B2. HSA Invitation Email IC Document
Appendix B3. HSA FAQs.docx Appendix B3. HSA Study Description/FAQs IC Document
Appendix B4. HSA Invitation Reminder Email.docx Appendix B4. HSA Invitation Reminder Email IC Document
Appendix B5. HSA Recruitment Telephone Script.docx Appendix B5. HSA Telephone Recruitment Script IC Document
Appendix B6. HSA Scheduling Email.docx Appendix B6. HSA Scheduling Email IC Document
Appendix B7. HSA Confirmation Email.docx Appendix B7. HSA Confirmation Email IC Document
Appendix B8. HSA Interview Reminder Email.docx Appendix B8. HSA Reminder Email IC Document
Appendix B9. HSA Reminder Telephone Script.docx Appendix B9. HSA Reminder Telephone Script IC Document
Appendix B10. HSA Thank You Email.docx Appendix B10. HSA Thank-You Email IC Document

Information Collection (IC) Details

IC Title:	Appendix B1. HSA Interview Guide	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	B1	Appendix B1. HSA Interview Guide	Appendix B1. HSA Discussion Guide_5-18-20.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 39	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	39	39
Annual IC Time Burden (Hours)	39	39
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Appendix B2. HSA Invitation Email	Appendix B2. HSA Invitation Email.docx	06/05/2020
Appendix B3. HSA Study Description/FAQs	Appendix B3. HSA FAQs.docx	06/05/2020
Appendix B4. HSA Invitation Reminder Email	Appendix B4. HSA Invitation Reminder Email.docx	06/05/2020
Appendix B5. HSA Telephone Recruitment Script	Appendix B5. HSA Recruitment Telephone Script.docx	06/05/2020
Appendix B6. HSA Scheduling Email	Appendix B6. HSA Scheduling Email.docx	06/05/2020
Appendix B7. HSA Confirmation Email	Appendix B7. HSA Confirmation Email.docx	06/05/2020
Appendix B8. HSA Reminder Email	Appendix B8. HSA Interview Reminder Email.docx	06/05/2020
Appendix B9. HSA Reminder Telephone Script	Appendix B9. HSA Reminder Telephone Script.docx	06/05/2020
Appendix B10. HSA Thank-You Email	Appendix B10. HSA Thank You Email.docx	06/05/2020

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