Form Approved
OMB No. 0990-
Exp. Date XX/XX/20XX
SERVICE DELIVERY FORM
TSU PATIENT CENTERED CARE COLLABORATION TO IMPROVE MINORITY HEALTH (PCCC) INITIATIVE
Directions: Complete this form at the end of post-intervention home visit. Pharmacist will send the completed form to the program coordinator.
Patient Name: _______________________
Pharmacist Name: ___________________________________
Post-Intervention Visit Date: ___________________________
Patient Signature: ____________________ Date: ____________________
Pharmacist Signature: _________________ Date: ____________________
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average (hours)(minutes) per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Department of Health and Human Services |
| File Modified | 0000-00-00 |
| File Created | 2021-01-31 |