Information Collection

Patients

IC 200544 under ICR 201112-0925-003 · OMB 0925-0659.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Demographics Patients	Form and Instruction
Form 2 Screener Patients	Form and Instruction
Form 3 Item Banks Patients	Form and Instruction
Form 4 PROMIS Patients	Form and Instruction
1 Demographics Attachment 1_Socio demographic Information Collected.docx	Form and Instruction
2 Screener Attachment 2_screener questions.docx	Form and Instruction
3 Item Banks OMB Copy of Item Banks.pdf	Form and Instruction
4 PROMIS PROMIS item bank.pdf	Form and Instruction

IC Title:

Patients

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Yes	Yes	Fillable Fileable
Form and Instruction	2	Yes	Yes	Fillable Fileable
Form and Instruction	3	No	No	Fillable Fileable
Form and Instruction	4	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,000

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	1,000	1,000
Annual IC Time Burden (Hours)	500	500
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.

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