Information Collection

Patients

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

Documents and Forms

Document Name Document Type
Form 1 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

Information Collection (IC) Details

View Information Collection (IC)

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:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Demographics	Attachment 1_Socio demographic Information Collected.docx	Yes	Yes	Fillable Fileable
Form and Instruction	2	Screener	Attachment 2_screener questions.docx	Yes	Yes	Fillable Fileable
Form and Instruction	3	Item Banks	OMB Copy of Item Banks.pdf	No	No	Fillable Fileable
Form and Instruction	4	PROMIS	PROMIS item bank.pdf	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 %

	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

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.