Information Collection

Interview Protocol for Emergency Department and Primary Care

IC 197249 under ICR 201105-0920-002 · OMB 0920-0887.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Interview Protocol for Emergency Department and Primary Care	Form
Interview Protocol for ED and PC clean_Attachment C--Interview Protocol 1--Emergency Department and Primary Care.doc	Form
clean_Attachment E--Invitation Letter.docx Att E - Interview Invitation	IC Document
clean_Attachment G--Confirmation Letter.doc Att G - Confirmation Letter	IC Document
clean_Attachment F--Follow-up Letter.docx Att F - Followup Letter	IC Document
clean_Attachment H--Thank-you Letter.doc Att H - Thank-you 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	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Interview Protocol for ED and PC	clean_Attachment C--Interview Protocol 1--Emergency Department and Primary Care.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 43

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

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	43	43
Annual IC Time Burden (Hours)	43	43
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att E - Interview Invitation	clean_Attachment E--Invitation Letter.docx	05/04/2011
Att G - Confirmation Letter	clean_Attachment G--Confirmation Letter.doc	05/04/2011
Att F - Followup Letter	clean_Attachment F--Follow-up Letter.docx	05/04/2011
Att H - Thank-you Letter	clean_Attachment H--Thank-you Letter.doc	05/04/2011

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