Information Collection

Referral/Consent to Contact Form - Patient

IC 183859 under ICR 200802-0920-009 · OMB 0920-0788.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form No number Referral/Consent to Contact Form - Patient	Form
No number Referral/Consent to Contact Form - Patient Attachment 7 Referral-Consent to Contact Form for Patient.doc	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	No number	Referral/Consent to Contact Form - Patient	Attachment 7 Referral-Consent to Contact Form for Patient.doc		Yes	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 507

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	507	507
Annual IC Time Burden (Hours)	101	101
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.