Information Collection

[NCCDPHP] Formative Evaluation, Implementation and Rapid Evaluation (FIRE) of Diabetes Self-Management in Disproportionately Affected Populations (DAPs) Provider Listening Sessions (Phase I)

IC 260016 under ICR 202503-0920-028 · OMB 0920-1154.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1154 can be found here:

Documents and Forms

Document Name Document Type
[NCCDPHP] Formative Evaluation, Implementation and Rapid Evaluation (FIRE) of Diabetes Self-Management in Disproportionately Affected Populations (DAPs) Provider Listening Sessions (Phase I) Form and Instruction
[NCCDPHP] Formative Evaluation, Implementation and Rapid Evaluation (FIRE) of Diabetes Self-Management in Disproportionately Affected Populations (DAPs) Provider Listening Sessions (Phase I) Form and Instruction
DSMES Provider Screener Script and Guidelines 1154 Att A FIRE Listening Sessions_DSMES Provider Screener_.docx Form and Instruction
DSMES Provider Screener Script and Guidelines 1154 Att A FIRE Listening Sessions_DSMES Provider Screener_.docx Form and Instruction
Listening Sessions Guide for Providers Who Support Peopl 1154 Att B FIRE Listening Session Guide PLD.docx Form and Instruction
Listening Sessions Guide for Providers Who Support Peopl 1154 Att B FIRE Listening Session Guide PLD.docx Form and Instruction
Listening Sessions Guide for Providers Who Support Minor 1154 Att C FIRE Listening Session Guide MW.docx Form and Instruction
Listening Sessions Guide for Providers Who Support Minor 1154 Att C FIRE Listening Session Guide MW.docx Form and Instruction
Listening Sessions Guide for Providers Who Support Peopl 1154 Att D FIRE Listening Session Guide PWMHD.docx Form and Instruction
Listening Sessions Guide for Providers Who Support Peopl 1154 Att D FIRE Listening Session Guide PWMHD.docx Form and Instruction
1154 SSA DDT_revised.docx Supporting Statement Part A IC Document
1154 SSA DDT_revised.docx Supporting Statement Part A IC Document
1154 SSB DDT.docx Supporting Statement Part B IC Document
1154 SSB DDT.docx Supporting Statement Part B IC Document
1154 Att E FIRE Recruitment Emails.docx Recruitment Emails IC Document
1154 Att E FIRE Recruitment Emails.docx Recruitment Emails IC Document
1154 Att F IRB Determination notice.pdf FHI360 Determination: IRB Approval is Not Required IC Document
1154 Att F IRB Determination notice.pdf FHI360 Determination: IRB Approval is Not Required IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	[NCCDPHP] Formative Evaluation, Implementation and Rapid Evaluation (FIRE) of Diabetes Self-Management in Disproportionately Affected Populations (DAPs) Provider Listening Sessions (Phase I)	Agency IC Tracking Number:	0920-1154-22HG

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	None	DSMES Provider Screener Script and Guidelines	1154 Att A FIRE Listening Sessions_DSMES Provider Screener_.docx	Yes	Yes	Fillable Fileable
Form and Instruction	None	Listening Sessions Guide for Providers Who Support People with Learning Disabilities	1154 Att B FIRE Listening Session Guide PLD.docx	Yes	Yes	Fillable Fileable
Form and Instruction	None	Listening Sessions Guide for Providers Who Support Minority Women	1154 Att C FIRE Listening Session Guide MW.docx	Yes	Yes	Fillable Fileable
Form and Instruction	None	Listening Sessions Guide for Providers Who Support People with Mental Health Disorders	1154 Att D FIRE Listening Session Guide PWMHD.docx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 150	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	150	150
Annual IC Time Burden (Hours)	68	68
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement Part A	1154 SSA DDT_revised.docx	05/04/2023
Supporting Statement Part B	1154 SSB DDT.docx	05/02/2023
Recruitment Emails	1154 Att E FIRE Recruitment Emails.docx	05/02/2023
FHI360 Determination: IRB Approval is Not Required	1154 Att F IRB Determination notice.pdf	05/02/2023

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