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Federal forms, ICRs, and supporting documents

Information Collection

Intervention Trials- Patient Eligibility Screener

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

Documents and Forms
Document Name
Document Type
Form
Form
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Intervention Trials- Patient Eligibility Screener
 
No New
 
Voluntary
 

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

Health Health Care Services

 

3,000 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 3,000 0 3,000 0 0 0
Annual IC Time Burden (Hours) 249 0 249 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.