Information Collection

Patient Interviews

IC 201013 under ICR 201202-0935-002 · OMB 0935-0193.

Documents and Forms

Document Name Document Type
Form Form #3 Patient Interviews Form and Instruction
Form #3 Patient Interview Questions Attachment E -- Patient Interview Questions.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Patient Interviews	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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form #3	Patient Interview Questions	Attachment E -- Patient Interview Questions.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 300	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	300	300
Annual IC Time Burden (Hours)	75	75
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.