Information Collection

Intervention Trials- Patient Eligibility Screener

IC 190432 under ICR 200908-0915-003 · OMB 0915-0330.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Tab 6 Intervention Trials- Patient Eligibility Screener	Form
Tab 6 Patient Eligibility Screener Tab 6 Eligibility Screening Form.doc	Form
Tab 5 Eligibility Criteria.doc Patient Eligibility Criteria	IC Document

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	Tab 6	Patient Eligibility Screener	Tab 6 Eligibility Screening Form.doc		Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,000

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	3,000	3,000
Annual IC Time Burden (Hours)	249	249
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Patient Eligibility Criteria	Tab 5 Eligibility Criteria.doc	08/04/2009

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