Information Collection

Patient Navigator Demonstration Program Evaluation - Patient Navigator Level

IC 188563 under ICR 200903-0915-003 · OMB 0915-0328.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 001 - Patient Navi Patient Navigator Tracking Log Patient Navigator Demonstration Program Evaluation - Patient Navigator Level	Form
Attachment A - HRSA PNDP Data Dictionary.pdf	Other-Data Dictionary
001 - Patient Navi Patient Navigator Tracking Log Attachment B - Patient Tracking Log.pdf	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
Other-Data Dictionary					Yes	Yes	Fillable Fileable
Form	001 - Patient Navigator Tracking Log				Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 30

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	22,530	22,530
Annual IC Time Burden (Hours)	5,633	5,633
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.

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