Information Collection

Caregiver Interview Guide

IC 270658 under ICR 202409-0920-002 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-23IE Caregiver Interview Guide	Form
0920-23IE Caregiver Interview Guide Attachment 6a cover sheet_Caregiver Interview Guide.docx	Form
Attachment 6b cover sheet_Caregiver Interview consent form.docx Caregiver Interview consent form	IC Document
Attachment 6c cover sheet_Caregiver Interview recruitment communications.docx Caregiver Interview recruitment communications	IC Document

IC Title:

Agency IC Tracking Number:

0920-23IE

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	0920-23IE	Caregiver Interview Guide	Attachment 6a cover sheet_Caregiver Interview Guide.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 20

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	20	20
Annual IC Time Burden (Hours)	20	20
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Caregiver Interview consent form	Attachment 6b cover sheet_Caregiver Interview consent form.docx	09/05/2024
Caregiver Interview recruitment communications	Attachment 6c cover sheet_Caregiver Interview recruitment communications.docx	09/05/2024

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