Extraction of medical record data

Connecting Primary Care Practices with Hard-to-Reach Adolescent Populations

Documents and Forms

Document Name Document Type
Form Form #2 Extraction of medical record data Form and Instruction
Form #2 Extraction of medical record data Attachment C -- Extraction of Medical Record Data.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Extraction of medical record data	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 #2	Extraction of medical record data	Attachment C -- Extraction of Medical Record Data.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	8	8
Annual IC Time Burden (Hours)	32	32
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.