Patient Focus Group Interview - Small Group Discussion Interview Guide

Develop and Implement UCARE4LIFE Message Library

Documents and Forms

Document Name Document Type
Form 1 Patient Focus Group Interview - Small Group Discussion Interview Guide Form and Instruction
1 Small Group Discussion Guide AppendixC_SmallGroupDiscussionGuide.docx Form and Instruction
2 AppendixS_SampleTextMessageInventory.docx 2 AppendixS_SampleTextMessageInventory IC Document
2 AppendixR_SmallGroupDiscussionReminderEmail.docx 2 AppendixR_SmallGroupDiscussionReminderEmail IC Document
AppendixK_1 Adolescent assent form for small group.docx AppendixK_1 Adolescent assent form for small group IC Document
AppendixK_2 Adult consent form for small group.docx AppendixK_2 Adult consent form for small group IC Document

Information Collection (IC) Details

IC Title:	Patient Focus Group Interview - Small Group Discussion Interview Guide	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 Guide	AppendixC_SmallGroupDiscussionGuide.docx		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 32	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	32	32
Annual IC Time Burden (Hours)	64	64
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
2 AppendixS_SampleTextMessageInventory	2 AppendixS_SampleTextMessageInventory.docx	08/30/2013
2 AppendixR_SmallGroupDiscussionReminderEmail	2 AppendixR_SmallGroupDiscussionReminderEmail.docx	08/30/2013
AppendixK_1 Adolescent assent form for small group	AppendixK_1 Adolescent assent form for small group.docx	08/30/2013
AppendixK_2 Adult consent form for small group	AppendixK_2 Adult consent form for small group.docx	08/30/2013

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