Patient Interview Phone Recruitment Script

Assessing Problem Areas in Referrals for Chronic Hematologic Malignancies and Developing Interventions to Address Them

Documents and Forms

Document Name Document Type
Att 5_Patient Interview Phone Recruitment Script 083109.doc Other-WORD

Information Collection (IC) Details

IC Title:	Patient Interview Phone Recruitment Script	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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
Other-WORD			Att 5_Patient Interview Phone Recruitment Script 083109.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: 09-20-0136, Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 62812

Number of Respondents: 50	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	50	0	50
Annual IC Time Burden (Hours)	2	0	2
Annual IC Cost Burden (Dollars)	0	-30	30

Documents for IC

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.