Information Collection

Patient Navigator Demonstration Program Evaluation - Grantee Level

IC 188564 under ICR 200903-0915-003 · OMB 0915-0328.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 003- Patient Navig Patient Navigator Grantee Quarterly Report Patient Navigator Demonstration Program Evaluation - Grantee Level	Form
Attachment A - HRSA PNDP Data Dictionary.pdf	Other-Data Dictionary
003- Patient Navig Patient Navigator Grantee Quarterly Report Attachment C - QuarterlyReport.pdf	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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	003- Patient Navigator Grantee Quarterly Report				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 6

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

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	12,060	12,060
Annual IC Time Burden (Hours)	12,060	12,060
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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