Information Collection

Prevalence and Clinical Course of Depression Among Patients with Heart Failure, VA HSR&D, Nursing Research Initiative No. 05-209-3

IC 184350 under ICR 201110-2900-002 · OMB 2900-0719.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form VA Form 10-21085a, Prevalence and Clinical Course of Depression Among Patients with Heart Failure, VA HSR&D, Nursing Research Initiative No. 05-209-3	Form and Instruction
VA Form 10-21085a, Prevalence and Clinical Course of Depression Among Patie Research_Questionnaire_Booklet1.pdf	Form and Instruction

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 and Instruction	VA Form 10-21085a, b,c,d,e	Prevalence and Clinical Course of Depression Among Patients with Heart Failure	Research_Questionnaire_Booklet1.pdf		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,014

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	5,014	5,014
Annual IC Time Burden (Hours)	1,362	1,362
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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