Information Collection

Staff at Primary Care Practices

IC 192998 under ICR 201005-0990-002 · OMB 0990-0361.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0361 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
0990-PatientPerspective_App H2 Patient Recruitment Script Spanish.doc	Other-Script
0990-PatientPerspective_App C Physician Practice Screener.doc	Other-Screener
0990-PatientPerspective_App F4 Patient Survey Fact Sheet Spanish.doc	Other-info
0990-PatientPerspective_App E2 Patient Survey Spanish.doc	Other-info
0990-PatientPerspective_App F3 Patient Letter Spanish.doc	Other-info
0990-PatientPerspective_App I Patient recruitment log.doc Log sheet	IC Document
0990-PatientPerspective_App D3 Medical practice Followup Letter.doc 0990-PatientPerspective_App D3 Medical practice Followup Letter	IC Document
0990-PatientPerspecive_App D2 Physician Practice Fact Sheet.doc 0990-PatientPerspecive_App D2 Physician Practice Fact Sheet	IC Document
0990-PatientPerspective_App D1 Physician Practice Advance Letter.doc 0990-PatientPerspective_App D1 Physician Practice Advance Letter	IC Document

IC Title:

Staff at Primary Care Practices

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Script	0990-PatientPerspective_App H2 Patient Recruitment Script Spanish.doc	No	No	Paper Only
Other-Screener	0990-PatientPerspective_App C Physician Practice Screener.doc	No	No	Paper Only
Other-info	0990-PatientPerspective_App F4 Patient Survey Fact Sheet Spanish.doc	No	No	Paper Only
Other-info	0990-PatientPerspective_App E2 Patient Survey Spanish.doc	No	No	Paper Only
Other-info	0990-PatientPerspective_App F3 Patient Letter Spanish.doc	No	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 42

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	42	42
Annual IC Time Burden (Hours)	11	11
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Log sheet	0990-PatientPerspective_App I Patient recruitment log.doc	05/04/2010
0990-PatientPerspective_App D3 Medical practice Followup Letter	0990-PatientPerspective_App D3 Medical practice Followup Letter.doc	05/04/2010
0990-PatientPerspecive_App D2 Physician Practice Fact Sheet	0990-PatientPerspecive_App D2 Physician Practice Fact Sheet.doc	05/04/2010
0990-PatientPerspective_App D1 Physician Practice Advance Letter	0990-PatientPerspective_App D1 Physician Practice Advance Letter.doc	05/04/2010

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