Information Collection

Referral/Consent to Contact Form - Patient

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Referral/Consent to Contact Form - Patient	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	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 %

	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

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.