Information Collection

Staff at Primary Care Practices

IC 192998 under ICR 201101-0990-001 · OMB 0990-0361.

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:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Script	No	No	Paper Only
Other-Screener	No	No	Paper Only
Other-info	No	No	Paper Only
Other-info	No	No	Paper Only
Other-info	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	Previously Approved
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		05/04/2010
0990-PatientPerspective_App D3 Medical practice Followup Letter		05/04/2010
0990-PatientPerspecive_App D2 Physician Practice Fact Sheet		05/04/2010
0990-PatientPerspective_App D1 Physician Practice Advance Letter		05/04/2010

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

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