RFCC Clinical Intake Form (Provider RFCCs)

The National Evaluation of the Rural/Frontier Women's Health Coordinator Center

Documents and Forms

Document Name Document Type
Appendix F-1_women's health registration_Utah_8-7-06.doc Other-form
Appendix F-2_women's health registration_TN_8-7-06.doc Other-form

Information Collection (IC) Details

IC Title:	RFCC Clinical Intake Form (Provider RFCCs)	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
Other-form			Appendix F-1_women's health registration_Utah_8-7-06.doc		No	No	Fillable Printable
Other-form			Appendix F-2_women's health registration_TN_8-7-06.doc		No	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 200	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	200	200
Annual IC Time Burden (Hours)	67	67
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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