Participant Screener and Recruitment Form

Formative Research to Support the Development of Sickle Cell Disease Educational Messages and Materials

Documents and Forms

Document Name Document Type
Att 5_Screener & Script.docx Other-WORD
SUPPLEMENTAL1_Permission Form for Parents of Adolescents Ages 15-17 (100511 (2).docx SUPPLEMENTAL1_Permission Form for Parents of Adolescents Ages 15-17 (100511 (2) IC Document
SUPPLEMENTAL2_Assent for Adolescents Aged 15-17 (100511) (2).docx SUPPLEMENTAL2_Assent for Adolescents Aged 15-17 (100511) (2) IC Document
SUPPLEMENTAL3_ Informed Consent for Adults (100511) (2).docx SUPPLEMENTAL3_ Informed Consent for Adults (100511) (2) IC Document

Information Collection (IC) Details

IC Title:	Participant Screener and Recruitment Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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
Other-WORD			Att 5_Screener & Script.docx		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 120	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	120	120
Annual IC Time Burden (Hours)	24	24
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SUPPLEMENTAL1_Permission Form for Parents of Adolescents Ages 15-17 (100511 (2)	SUPPLEMENTAL1_Permission Form for Parents of Adolescents Ages 15-17 (100511 (2).docx	05/10/2013
SUPPLEMENTAL2_Assent for Adolescents Aged 15-17 (100511) (2)	SUPPLEMENTAL2_Assent for Adolescents Aged 15-17 (100511) (2).docx	05/10/2013
SUPPLEMENTAL3_ Informed Consent for Adults (100511) (2)	SUPPLEMENTAL3_ Informed Consent for Adults (100511) (2).docx	05/10/2013

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