Assessment of Chronic Illness Care (ACIC)

Studying the Implementation of a Chronic Care Toolkit and Practice Coaching In Practices Serving Vulnerable Populations

Documents and Forms

Document Name Document Type
Form Form #6 Assessment of Chronic Illness Care (ACIC) Form and Instruction
Form #6 Assessment of Chronic Illness Care (ACIC) Attachment G - Assessment of Chronic Illness Care (ACIC) Questionnaire.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Assessment of Chronic Illness Care (ACIC)	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 #6	Assessment of Chronic Illness Care (ACIC)	Attachment G - Assessment of Chronic Illness Care (ACIC) Questionnaire.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: 10	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	240	240
Annual IC Time Burden (Hours)	120	120
Annual IC Cost Burden (Dollars)	0	0

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.