Information Collection

Patient Short interview

IC 178498 under ICR 201203-0920-011 · OMB 0920-0740.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0740 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2b Patient Short interview	Form and Instruction
2b 2012 Short Interview Questionnaire for Medical Monitorin Att_2b short interview v8 1 1.docx	Form and Instruction

IC Title:

Patient Short interview

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	2b	2012 Short Interview Questionnaire for Medical Monitoring Project (MMP)	Att_2b short interview v8 1 1.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 301

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	301	2	299
Annual IC Time Burden (Hours)	100	0	100
Annual IC Cost Burden (Dollars)	0	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.