Information Collection

Patients at Primary Care Practices

IC 192999 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 E1 Patient Survey English.doc	Other-questionnaire
0990-PatientPerspective_App F2 Patient Survey Fact Sheet English.doc	Other-letter
0990-PatientPerspective_App G PracticeThank You letter.doc 0990-PatientPerspective_App G PracticeThank You letter	IC Document
0990-PatientPerspective_App F1 Patient Letter English.doc 0990-PatientPerspective_App F1 Patient Letter English	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	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-questionnaire	0990-PatientPerspective_App E1 Patient Survey English.doc	No	No	Paper Only
Other-letter	0990-PatientPerspective_App F2 Patient Survey Fact Sheet English.doc	No	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 840

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	840	840
Annual IC Time Burden (Hours)	210	210
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
0990-PatientPerspective_App G PracticeThank You letter	0990-PatientPerspective_App G PracticeThank You letter.doc	05/04/2010
0990-PatientPerspective_App F1 Patient Letter English	0990-PatientPerspective_App F1 Patient Letter English.doc	05/04/2010

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