Grantee Health Care Provider Focus Group

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⚠️ Notice: This information collection may be referencing outdated material.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 14 Grantee Health Care Provider Focus Group Form and Instruction
15 Participant Information Form PARTICIPANT_INFORMATION_FORM.doc Form and Instruction
14 Consent Form Consent_for_PNDP_Discussion_Questions_3-7-11_doc.doc Form and Instruction
12 Focus_Group_Health_Provider PNDP2_FocusGroup_HealthCareProv.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Grantee Health Care Provider Focus Group	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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	14	Consent Form	Consent_for_PNDP_Discussion_Questions_3-7-11_doc.doc	Yes	No	Printable Only
Form and Instruction	12	Focus_Group_Health_Provider	PNDP2_FocusGroup_HealthCareProv.doc	Yes	No	Printable Only
Form and Instruction	15	Participant Information Form	PARTICIPANT_INFORMATION_FORM.doc	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 30	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	30	30
Annual IC Time Burden (Hours)	30	30
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.