Formative Assessment of Barriers to Transition from Adolescent to Adult for Individuals with Congenital Heart Defects

CDC/ATSDR Formative Research and Tool Development

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1154 can be found here:

Documents and Forms

Document Name Document Type
Formative Assessment of Barriers to Transition from Adolescent to Adult for Individuals with Congenital Heart Defects Form
Survey of Parents of Adolescents with Congenital Heart D Att. 1_surveyinstrument_4.13.2017.docx Form
GenICRequestTemplate_Congenital heart defects_jg_tmj04.12.2017.docx Request for Approval IC Document
SS_A_CHDtransitionsurvey_4.11.17v3.docx Supporting Statement A IC Document
SS_B_CHDtransitionsurvey_4.12.17v3.docx Supporting Statement B IC Document
Att. 2_SupplementalForm1_EmoryTelephoneScript.docx Emory Recruitment Script IC Document
Att. 3_SupplementalForm2_NYSDOHPreNotificationLetter (003).docx Pre-notification Letter IC Document
Att. 4_SupplementalForm3_NYSDOHIntroLetter (003).docx Introductory Letter IC Document
Att. 5_SupplementalForm4_NYSDOHReminderLetter.docx Reminder Letter IC Document
Att. 6_SupplementalForm5_NYSDOHReminderPostcard (003).docx Reminder Postcard IC Document
Att.7_SupplementalForm6_NYSDOHThankyouLetter.docx Thank you Letter IC Document
Att. 8_rpt684_IRB_Form (004).pdf Nonresearch Determination IC Document

Information Collection (IC) Details

IC Title:	Formative Assessment of Barriers to Transition from Adolescent to Adult for Individuals with Congenital Heart Defects	Agency IC Tracking Number:	17AAA

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	none	Survey of Parents of Adolescents with Congenital Heart Defects	Att. 1_surveyinstrument_4.13.2017.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,100	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 30 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,100	1,100
Annual IC Time Burden (Hours)	367	367
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Request for Approval	GenICRequestTemplate_Congenital heart defects_jg_tmj04.12.2017.docx	04/13/2017
Supporting Statement A	SS_A_CHDtransitionsurvey_4.11.17v3.docx	04/13/2017
Supporting Statement B	SS_B_CHDtransitionsurvey_4.12.17v3.docx	04/13/2017
Emory Recruitment Script	Att. 2_SupplementalForm1_EmoryTelephoneScript.docx	04/13/2017
Pre-notification Letter	Att. 3_SupplementalForm2_NYSDOHPreNotificationLetter (003).docx	04/13/2017
Introductory Letter	Att. 4_SupplementalForm3_NYSDOHIntroLetter (003).docx	04/13/2017
Reminder Letter	Att. 5_SupplementalForm4_NYSDOHReminderLetter.docx	04/13/2017
Reminder Postcard	Att. 6_SupplementalForm5_NYSDOHReminderPostcard (003).docx	04/13/2017
Thank you Letter	Att.7_SupplementalForm6_NYSDOHThankyouLetter.docx	04/13/2017
Nonresearch Determination	Att. 8_rpt684_IRB_Form (004).pdf	04/13/2017

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