Patient Assessment of Chronic Illness Care (PACIC)

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 #9 Patient Assessment of Chronic Illness Care (PACIC) Form and Instruction
Form #9 Patient Assessment of Chronic Illness Care (PACIC) Attachment J - Patient Assessment of Chronic Illness Care (PACIC) Questionnaire.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Patient Assessment of Chronic Illness Care (PACIC)	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 #9	Patient Assessment of Chronic Illness Care (PACIC)	Attachment J - Patient Assessment of Chronic Illness Care (PACIC) 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: 1,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,500	1,500
Annual IC Time Burden (Hours)	375	375
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.