Information Collection

Patient Navigator ultural Competency Checklist

IC 198110 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form 10 Patient Navigator ultural Competency Checklist Form and Instruction
10 Cultural Competency HRSA_Patient_Navigator_Demonstration_Program_Cultural_Competency_Checklist.doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Patient Navigator ultural Competency Checklist	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	10	Cultural Competency	HRSA_Patient_Navigator_Demonstration_Program_Cultural_Competency_Checklist.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	46	46
Annual IC Time Burden (Hours)	54	54
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.