Ethnicity & Race: Messaging to Improve Patient-Provider Communication and Engagement on Risks of Alcohol Use During Pregnancy

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⚠️ Notice: This information collection may be referencing outdated material.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
Form 0920-1154 Ethnicity & Race: Messaging to Improve Patient-Provider Communication and Engagement on Risks of Alcohol Use During Pregnancy Form and Instruction
Attachment E_ Provider Online Survey Screenshots.pdf Other-Screenshots
Attachment F_Provider IDI Guide_all_instruments_combined.docx Other-WORD
Attachment G_CDC FASD recruitment communications_1May2019_clean.docx Instruction
Attachment H_Women_IDI_Screener_1May2019_clean.docx Other-WORD
Attachment I FASD Screener for Women of Reproductive Age Screenshots.pdf Other-Screenshots
Attachment J_Landing page screenshot.png Other-Screenshots
0920-1154 Consent Form Provider (Online Survey) Attachment A_ConsentForm_ProviderSurvey_Mar2019.docx Form and Instruction
0920-1154 Consent Form Provider In-Depth Interview Attachment B_ConsentForm_ProviderIDI_Mar2019.docx Form and Instruction
0920-1154 Consent Form Women In-Depth Interview Attachment C_ConsentForm_WomenIDI.docx Form and Instruction
0920-1154 Provider Screener and Online Survey Attachment D_Provider Screener and Online Survey.docx Form
Attachment L_IRB_Approval_Letter.pdf Att L_IRB IC Document
Supporting Statement A_03_21_19.docx Supporting Statement A IC Document
Supporting Statement B_03_21_19.docx Supporting Statement B IC Document
GenICRequestTemplate_AIR_052418.docx Request for Approval IC Document

Information Collection (IC) Details

IC Title:	Ethnicity & Race: Messaging to Improve Patient-Provider Communication and Engagement on Risks of Alcohol Use During Pregnancy	Agency IC Tracking Number:	0920-1154-19AUM

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-1154	Consent Form Provider (Online Survey)	Attachment A_ConsentForm_ProviderSurvey_Mar2019.docx	Yes	Yes	Fillable Fileable
Form and Instruction	0920-1154	Consent Form Provider In-Depth Interview	Attachment B_ConsentForm_ProviderIDI_Mar2019.docx	No		Paper Only
Form and Instruction	0920-1154	Consent Form Women In-Depth Interview	Attachment C_ConsentForm_WomenIDI.docx	No		Fillable Fileable Signable
Form	0920-1154	Provider Screener and Online Survey	Attachment D_Provider Screener and Online Survey.docx	Yes	Yes	Fillable Fileable
Other-Screenshots			Attachment E_ Provider Online Survey Screenshots.pdf	No		Paper Only
Other-WORD			Attachment F_Provider IDI Guide_all_instruments_combined.docx	No		Paper Only
Instruction			Attachment G_CDC FASD recruitment communications_1May2019_clean.docx	Yes	No	Printable Only
Other-WORD			Attachment H_Women_IDI_Screener_1May2019_clean.docx	No		Printable Only
Other-Screenshots			Attachment I FASD Screener for Women of Reproductive Age Screenshots.pdf	No		Paper Only
Other-Screenshots			Attachment J_Landing page screenshot.png	No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 900	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	900	900
Annual IC Time Burden (Hours)	307	307
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att L_IRB	Attachment L_IRB_Approval_Letter.pdf	05/07/2019
Supporting Statement A	Supporting Statement A_03_21_19.docx	05/07/2019
Supporting Statement B	Supporting Statement B_03_21_19.docx	05/07/2019
Request for Approval	GenICRequestTemplate_AIR_052418.docx	05/07/2019

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