Information Collection Request

ACCESS, EXCHANGE, AND USE OF SOCIAL DETERMINANTS OF HEALTH DATA IN CLINICAL NOTES

ICR 202103-0955-002 · OMB 0955-0021 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form D5 Synchronous Focus Group Consent-Patients and Care Partners (English).docx Form New Repair queued
Form D2 Asynchronous Focus Group Consent-Patients and Care Partners Form New Repair queued
Form D4 Final Synchronous Focus Group Consent-Patient and Care Partners (Spanish) Form New Repair queued
Form D3 Final Synchronous Focus Group Consent-Clinicians and Healthcare Professionals Form New Repair queued
Form D1 Final Asynchronous Focus Group Consent-Clinicians and Healthcare Professionals Form New Repair queued
Form C3 Synchronous Focus Group Interview Questions-Clinicians and Healthcare Professionals Form New Repair queued
Form C3 Synchronous Focus Group Questions for Clinicians and Healthcare Professionals Form New Repair queued
Form C5 Synchronous Focus Group Questions for Patients and Care Partners (Spanish) Form New Repair queued
Form C5 Synchronous Focus Group Questions for Patients and Care Partners (Spanish) Form New Repair queued
Form B3 Prescreening Questionnaire for Patients and Care Partners (Spanish) Form New Repair queued
Form B3 Prescreening Questionnaire for Patients and Care Partners (Spanish) Form New Repair queued
Form C1 Asynchronous Focus Group Questions-Clinicians and Healthcare Professionals Form New Repair queued
Form C1 Asynchronous Focus Group Questions for Clinicians and Healthcare Professionals Form New Repair queued
Form C4 Synchronous Focus Group Questions for Patients and Care Partners Form New Repair queued
Form C4 Synchronous Focus Group Questions for Patients and Care Partners Form New Repair queued
Form C2 Asynchronous Focus Group Questions-Patients and Care Partners Form New Repair queued
Form C2 Asynchronous Focus Group Questions for Patients and Care Partners Form New Repair queued
Form B1 Prescreening Questionnaire for Clinicians and Healthcare Professionals Form New Repair queued
Form B1 Prescreening Questionnaire for Clinicians and Healthcare Professionals Form New Repair queued
Form B2 Patients and Care Partners Prescreening Questionnaire Form New Repair queued
Form B2 Prescreening Questionnaire for Patients and Care Partners Form New Repair queued
Final Supporting Statement A 10-28-2021.docx Supporting Statement A Uploaded 2021-10-28 Repair queued
Attachment D5. Final Synchronous Focus Group Consent-Patients and Care Partners (English).docx Supplementary Document Uploaded 2021-10-12 Repair queued
Attachment D4. Final Synchronous Focus Group Consent-Patient and Care Partners (Spanish).docx Supplementary Document Uploaded 2021-10-12 Repair queued
Attachment D3. Final Synchronous Focus Group Consent-Clinicians and Healthcare Professionals.docx Supplementary Document Uploaded 2021-10-12 Repair queued
Attachment D1. Final Asynchronous Focus Group Consent-Clinicians and Healthcare Professionals.docx Supplementary Document Uploaded 2021-10-12 Repair queued
Attachment D2. Final Asynchronous Focus Group Consent-Patients and Care Partners.docx Supplementary Document Uploaded 2021-10-12 Repair queued
Final Supporting Statement B 8.9.21.docx Supporting Statement B Uploaded 2021-10-12 Repair queued

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
254883 Synchronous Focus Group Consent - Patients and Care Partners Form NewSynchronous Focus Group Consent-Patients and Care Partners (English).docx
254882 Asynchronous Focus Group Consent - Patients and Care Partners Form NewAsynchronous Focus Group Consent-Patients and Care Partners
254879 Synchronous Focus Group Consent (Spanish) - Patients and Care Partners Form NewFinal Synchronous Focus Group Consent-Patient and Care Partners (Spanish)
254877 Synchronous Focus Group Consent - Clinician and Healthcare Professionals Form NewFinal Synchronous Focus Group Consent-Clinicians and Healthcare Professionals
254817 Asynchronous Focus Group Consent-Clinicians and Healthcare Professionals Form NewFinal Asynchronous Focus Group Consent-Clinicians and Healthcare Professionals
249707 Synchronous Focus Group Questions for Clinicians and Healthcare Professionals Form NewSynchronous Focus Group Interview Questions-Clinicians and Healthcare Professionals
249707 Synchronous Focus Group Questions for Clinicians and Healthcare Professionals Form New
248132 Synchronous Focus Group Questions for Patients and Care Partners (Spanish) Form NewSynchronous Focus Group Questions for Patients and Care Partners (Spanish)
248132 Synchronous Focus Group Questions for Patients and Care Partners (Spanish) Form New
248131 Prescreening Questionnaire for Patients and Care Partners (Spanish) Form NewPrescreening Questionnaire for Patients and Care Partners (Spanish)
248131 Prescreening Questionnaire for Patients and Care Partners (Spanish) Form New
247992 Asynchronous Focus Group Questions for Clinicians and Healthcare Professionals Form NewAsynchronous Focus Group Questions-Clinicians and Healthcare Professionals
247992 Asynchronous Focus Group Questions for Clinicians and Healthcare Professionals Form New
247985 Synchronous Focus Group Questions for Patients and Care Partners Form NewSynchronous Focus Group Questions for Patients and Care Partners
247985 Synchronous Focus Group Questions for Patients and Care Partners Form New
247984 Asynchronous Focus Group Questions for Patients and Care Partners Form NewAsynchronous Focus Group Questions-Patients and Care Partners
247984 Asynchronous Focus Group Questions for Patients and Care Partners Form New
247983 Prescreening Questionnaire for Clinicians and Healthcare Professionals Form NewPrescreening Questionnaire for Clinicians and Healthcare Professionals
247983 Prescreening Questionnaire for Clinicians and Healthcare Professionals Form New
246469 Prescreening Questionnaire for Patients and Care Partners Form NewPatients and Care Partners Prescreening Questionnaire
246469 Prescreening Questionnaire for Patients and Care Partners Form New

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
08/31/2025 36 Months From Approved
1,900 0 0
426 0 0
0 0 0





Reginfo record details
13
table that charts list of burden
IC Title Form No. Form Name
Synchronous Focus Group Consent - Clinician and Healthcare Professionals D3
Asynchronous Focus Group Consent - Patients and Care Partners D2
Asynchronous Focus Group Consent-Clinicians and Healthcare Professionals D1
Asynchronous Focus Group Questions for Clinicians and Healthcare Professionals C1
Asynchronous Focus Group Questions for Patients and Care Partners C2
Prescreening Questionnaire for Clinicians and Healthcare Professionals B1
Prescreening Questionnaire for Patients and Care Partners B2
Prescreening Questionnaire for Patients and Care Partners (Spanish) B3
Synchronous Focus Group Consent (Spanish) - Patients and Care Partners D4
Synchronous Focus Group Consent - Patients and Care Partners D5
Synchronous Focus Group Questions for Clinicians and Healthcare Professionals C3
Synchronous Focus Group Questions for Patients and Care Partners C4
Synchronous Focus Group Questions for Patients and Care Partners (Spanish) C5

table that charts list of burden
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 1,900 0 0 1,900 0 0
Annual Time Burden (Hours) 426 0 0 426 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No