Information Collection

Patient Navigator Encounter/Target Services Log

IC 198106 under ICR 201112-0915-005 · OMB 0915-0346.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.