Information Collection

Patient Assessment, Clinton Service Unit, IMPRESS

IC 204388 under ICR 201205-0917-002 · OMB 0917-0036.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0917-0036 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0917-0036-11 Patient Assessment, Clinton Service Unit, IMPRESS	Form and Instruction
0917-0036-11 OMB No. 0917-0036-11, Patient Assessment OMB Form 0917-0036-11 IMPRESS Patient Assessment.pub	Form and Instruction
OMB No. 0917-0036-11, Mini-Supporting Statement.pdf OMB No. 0917-0011, Mini -Supporting Statement	IC Document

IC Title:

Patient Assessment, Clinton Service Unit, IMPRESS

Agency IC Tracking Number:

IC Status: New

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	0917-0036-11	OMB No. 0917-0036-11, Patient Assessment	OMB Form 0917-0036-11 IMPRESS Patient Assessment.pub		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 30 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	42	42
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
OMB No. 0917-0011, Mini -Supporting Statement	OMB No. 0917-0036-11, Mini-Supporting Statement.pdf	09/17/2012

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.