Patient Focus Group Screener - Small Group Discussion Screener

Develop and Implement UCARE4LIFE Message Library

Documents and Forms

Document Name Document Type
Form 1 Patient Focus Group Screener - Small Group Discussion Screener Form and Instruction
1 Small Group Discussion Screener AppendixB_SmallGroupDiscussionScreener.docx Form and Instruction
AppendixA_SmallGroupDiscussionRecruitmentFlyer.pub AppendixA_SmallGroupDiscussionRecruitmentFlyer IC Document
1 AppendixQ_SmallGroupDiscussionElectronicAd.docx 1 AppendixQ_SmallGroupDiscussionElectronicAd IC Document

Information Collection (IC) Details

IC Title:	Patient Focus Group Screener - Small Group Discussion Screener	Agency IC Tracking Number:

Is this a Common Form? No		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	Small Group Discussion Screener	AppendixB_SmallGroupDiscussionScreener.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 128	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	128	128
Annual IC Time Burden (Hours)	32	32
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
AppendixA_SmallGroupDiscussionRecruitmentFlyer	AppendixA_SmallGroupDiscussionRecruitmentFlyer.pub	08/30/2013
1 AppendixQ_SmallGroupDiscussionElectronicAd	1 AppendixQ_SmallGroupDiscussionElectronicAd.docx	08/30/2013

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