Information Collection

Prevention Is Care (PIC) Material Testing Interview

IC 183182 under ICR 201104-0920-002 · OMB 0920-0775.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Prevention Is Care (PIC) Material Testing Interview	Form
Prevention is Care Interview A2b Data Collection Instruments-PIC.docx	Form
A5b_Consent Forms-PIC_3-1-11.doc Consent - Prevention is Care	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	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Prevention is Care Interview	A2b Data Collection Instruments-PIC.docx		No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 48

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	Previously Approved
Annual Number of Responses for this IC	48	-6	54
Annual IC Time Burden (Hours)	48	-6	54
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Consent - Prevention is Care	A5b_Consent Forms-PIC_3-1-11.doc	03/23/2011

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