Sub-study #5_Patient Perspectives and Simulated Clinical Interactions

A Generic Submission for Theory Development and Validation (NCI)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0645 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Sub-study #5_Patient Perspectives and Simulated Clinical Interactions Form and Instruction
1 Simulated Clinical Interaction Survey Attach5B_Questionniare_Screenshots.pdf Form and Instruction
Sub-Study #5_Justif Memo_Doctor_Interaction_7-22-2013.doc Sub-Study #5_Justif Memo_Doctor_Interaction_7-22-2013 IC Document
Attach5A DoctorScript.doc Attach5A DoctorScript IC Document
Attach5C Key Readings.docx Attach5C Key Readings IC Document
Attach5D Consent Form.docx Attach5D Consent Form IC Document
Attach5E IRB Review.pdf Attach5E IRB Review IC Document

Information Collection (IC) Details

IC Title:	Sub-study #5_Patient Perspectives and Simulated Clinical Interactions	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Simulated Clinical Interaction Survey	Attach5B_Questionniare_Screenshots.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 700	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	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	700	0	0	0	0	0
Annual IC Time Burden (Hours)	350	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Sub-Study #5_Justif Memo_Doctor_Interaction_7-22-2013	Sub-Study #5_Justif Memo_Doctor_Interaction_7-22-2013.doc	07/22/2013
Attach5A DoctorScript	Attach5A DoctorScript.doc	07/22/2013
Attach5C Key Readings	Attach5C Key Readings.docx	07/22/2013
Attach5D Consent Form	Attach5D Consent Form.docx	07/22/2013
Attach5E IRB Review	Attach5E IRB Review.pdf	07/22/2013

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