Patient Navigator Encounter/Target Services Log

Patient Navigator Outreach and Chronic Disease Prevention Demonstration Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0346 can be found here:

Documents and Forms

Document Name Document Type
Form 4 Patient Navigator Encounter/Target Services Log Form and Instruction
4 Forms_20110919.v1 Forms_20110919.v1.pdf Form and Instruction
5 Target Services Log HRSA_Patient_Navigator_Demonstration_Program_Target_Form.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Patient Navigator Encounter/Target Services Log	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	4	Forms_20110919.v1	Forms_20110919.v1.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	5	Target Services Log	HRSA_Patient_Navigator_Demonstration_Program_Target_Form.doc		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 46	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	28,962	28,962
Annual IC Time Burden (Hours)	7,241	7,241
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.