FDPIR Tribal Leaders, Managers, Staff (State/Local/ Tribal Government)

OMB NUMBER: 0584-XXXX

EXPIRATION DATE: XX-XX-20XX

ATTACHMENT B1c: CASE RECORD REVIEW PRETEST OUTREACH SCRIPT

BURDEN DISCLOSURE STATEMENT

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-XXXX. The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data sources, gather the data needed, and complete and review the information collection.

CASE RECORD REVIEW PRETEST OUTREACH SCRIPT

Thank you so much for agreeing to be part of the FDPIR pretest. Your clients will find the interview experience very interesting.

In addition to the client interviewers, the study is conducting a case record review at each of the sites selected for participation. The objective of this is to obtain an updated demographic profile of participants. As with the interview, I would like to stress that strict rules of confidentiality are followed and names of the participants will not be collected from the records.

Are the records electronic or hard copy?

Hard Copy: Would it be possible for you to pull the records of the selected clients when the NORC staff member is visiting on (day/date/time)? It will just take a short time to abstract the data needed. S/he can show you what information they will be gathering. The data abstracted will be entered into a secure laptop. Just to remind you, no identifying information will be entered.

Electronic File: Will you be available when the NORC staff member is visiting on (day/date/time)? Could you or one of your staff members assist with sharing the files with the NORC staff member? The abstracted data will be entered into a secure laptop. Just to remind you, no identifying information will be entered.

Verify appointment details. Be sure person you are speaking with has your contact information.