Asthma questionnaire -- Nemours

Evaluation of the GuideLines Into Decision Support (GLIDES)

Documents and Forms

Document Name Document Type
Form Form #2 Asthma questionnaire -- Nemours Form and Instruction
Form #2 Asthma questionnaire -- Nemours Attachment C - Asthma questionnaire - Nemours.doc Form and Instruction
Attachment J -- Online Asthma Questionnaire - Nemours.pdf Attachment J -- Online Asthma Questionnaire - Nemours IC Document

Information Collection (IC) Details

IC Title:	Asthma questionnaire -- Nemours	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form #2	Asthma questionnaire -- Nemours	Attachment C - Asthma questionnaire - Nemours.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	110	110
Annual IC Time Burden (Hours)	11	11
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment J -- Online Asthma Questionnaire - Nemours	Attachment J -- Online Asthma Questionnaire - Nemours.pdf	02/03/2010

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