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 202507-0920-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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
DSMES Provider Screener Script and Guidelines [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
Listening Sessions Guide for Providers Who Support People with Learning Disabilities [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
Listening Sessions Guide for Providers Who Support Minority Women [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
Listening Sessions Guide for Providers Who Support People with Mental Health Disorders [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:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	None	Yes	Yes	Fillable Fileable
Form and Instruction	None	Yes	Yes	Fillable Fileable
Form and Instruction	None	Yes	Yes	Fillable Fileable
Form and Instruction	None	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 %

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement Part A		05/04/2023
Supporting Statement Part B		05/02/2023
Recruitment Emails		05/02/2023
FHI360 Determination: IRB Approval is Not Required		05/02/2023

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

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