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Federal forms, ICRs, and supporting documents

Information Collection

CHW Program Modules

IC 266245 under ICR 202403-0990-008 · OMB 0990-0482.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form Module 1
CHW Program Modules		 Form and Instruction
Module 1 Community Clinical Linkages: Enhancing Collabora
PrePost assessment CHW Pilot Program - 1 Enhancing Collaborative Care.pdf 		Form and Instruction
Module 1 Community Clinical Linkages: Enhancing Collabora
PrePost assessment CHW Pilot Program - 1 Enhancing Collaborative Care.pdf 		Form and Instruction
Module 2 High blood Pressure Awareness: All about High Blood Pres
PrePost assessment CHW Pilot Program - 2 All about High Blood Pressure.pdf 		Form and Instruction
Module 2 High blood Pressure Awareness: All about High Blood Pres
PrePost assessment CHW Pilot Program - 2 All about High Blood Pressure.pdf 		Form and Instruction
Module 3 Being Proactive with HBP: Identifying Risk Factors and I
PrePost assessment CHW Pilot Program - 3 Being Proactive with High Blood Pressure.pdf 		Form and Instruction
Module 3 Being Proactive with HBP: Identifying Risk Factors and I
PrePost assessment CHW Pilot Program - 3 Being Proactive with High Blood Pressure.pdf 		Form and Instruction
Module 4 Blood Pressure Screenings: Assessing BP and Interpreting
PrePost assessment CHW Pilot Program - 4 Assessing and Interpreting BP Results.pdf 		Form and Instruction
Module 4 Blood Pressure Screenings: Assessing BP and Interpreting
PrePost assessment CHW Pilot Program - 4 Assessing and Interpreting BP Results.pdf 		Form and Instruction
Module 5 Preventive Strategies for High Blood Pressure: Promoting
PrePost assessment CHW Pilot Program - 5 Preventative Strategies for High Blood Pressure.pdf 		Form and Instruction
Module 5 Preventive Strategies for High Blood Pressure: Promoting
PrePost assessment CHW Pilot Program - 5 Preventative Strategies for High Blood Pressure.pdf 		Form and Instruction
Module 6 Social Determinants of Health: Assessment, Navigation, a
PrePost assessment CHW Pilot Program - 6 Social Determinants of Health.pdf 		Form and Instruction
Module 6 Social Determinants of Health: Assessment, Navigation, a
PrePost assessment CHW Pilot Program - 6 Social Determinants of Health.pdf 		Form and Instruction
Module 7 Care Coordination: Effective Collaboration with Health C
PrePost assessment CHW Pilot Program - 7 Care Coordination.pdf 		Form and Instruction
Module 7 Care Coordination: Effective Collaboration with Health C
PrePost assessment CHW Pilot Program - 7 Care Coordination.pdf 		Form and Instruction

Information Collection (IC) Details

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Information Collection Instruments:
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Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction Module 1 Community Clinical Linkages: Enhancing Collabora􀆟ve Care PrePost assessment CHW Pilot Program - 1 Enhancing Collaborative Care.pdf Yes Yes Fillable Fileable
Form and Instruction Module 2 High blood Pressure Awareness: All about High Blood Pressure PrePost assessment CHW Pilot Program - 2 All about High Blood Pressure.pdf Yes Yes Fillable Fileable
Form and Instruction Module 3 Being Proactive with HBP: Identifying Risk Factors and Implementing Effective Program PrePost assessment CHW Pilot Program - 3 Being Proactive with High Blood Pressure.pdf Yes Yes Fillable Fileable
Form and Instruction Module 4 Blood Pressure Screenings: Assessing BP and Interpreting Readings PrePost assessment CHW Pilot Program - 4 Assessing and Interpreting BP Results.pdf Yes Yes Fillable Fileable
Form and Instruction Module 5 Preventive Strategies for High Blood Pressure: Promoting Healthy Lifestyles PrePost assessment CHW Pilot Program - 5 Preventative Strategies for High Blood Pressure.pdf Yes Yes Fillable Fileable
Form and Instruction Module 6 Social Determinants of Health: Assessment, Navigation, and Monitoring PrePost assessment CHW Pilot Program - 6 Social Determinants of Health.pdf Yes Yes Fillable Fileable
Form and Instruction Module 7 Care Coordination: Effective Collaboration with Health Care Professionals PrePost assessment CHW Pilot Program - 7 Care Coordination.pdf Yes Yes Fillable Fileable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 4,200 0 4,200 0 0 0
Annual IC Time Burden (Hours) 700 0 700 0 0 0
Annual IC Cost Burden (Dollars) 16,793 0 16,793 0 0 0

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