Information Collection

Patients Standard Interview

IC 178497 under ICR 201002-0920-010 · OMB 0920-0740.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0740 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Patients Standard Interview	Form
Patient Standard Interview 0920_0740_2011 MMP Questionnaire.docx	Form
Attachment11_Model Scripts.doc Provider/Patient Model Scripts	IC Document

IC Title:

Patients Standard Interview

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	none	Patient Standard Interview	0920_0740_2011 MMP Questionnaire.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,172

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 Agency Discretion	Previously Approved
Annual Number of Responses for this IC	7,172	-816	7,988
Annual IC Time Burden (Hours)	5,379	-612	5,991
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Provider/Patient Model Scripts	Attachment11_Model Scripts.doc	03/12/2009

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