Information Collection

Synchronous Focus Group Consent - Patients and Care Partners

IC 254883 under ICR 202103-0955-002 · OMB 0955-0021.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form D5 Synchronous Focus Group Consent-Patients and Care Partners (English).docx Synchronous Focus Group Consent - Patients and Care Partners	Form
D5 Synchronous Focus Group Consent-Patients and Care Partne Attachment D5. Final Synchronous Focus Group Consent-Patients and Care Partners (English).docx	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	D5				Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 80

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	80	80
Annual IC Time Burden (Hours)	7	7
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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

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