Information Collection

Follow-up Patient Survey

IC 188620 under ICR 201205-0920-008 · OMB 0920-0814.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Follow-up Patient Survey	Form
Follow-up Patient Survey D1 Follow-up Patient Survey.doc	Form
D1a Patient Consent Survey.pdf Patient Consent	IC Document
D1c Cover Letter for Patient Follow-up Survey.docx Cover Letter	IC Document
D1b Initial Postcard.doc Initial Postcard	IC Document
D1d Reminder postcard.doc Reminder Postcard	IC Document
D1e SCRIPT FOR REMINDER TELEPHONE CALL.doc Telephone Reminder Script	IC Document

IC Title:

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	none	Follow-up Patient Survey	D1 Follow-up Patient Survey.doc		Yes	No	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 252

Number of Respondents: 150

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	150	144	6
Annual IC Time Burden (Hours)	25	13	12
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Patient Consent	D1a Patient Consent Survey.pdf	05/17/2012
Cover Letter	D1c Cover Letter for Patient Follow-up Survey.docx	05/17/2012
Initial Postcard	D1b Initial Postcard.doc	05/17/2012
Reminder Postcard	D1d Reminder postcard.doc	05/17/2012
Telephone Reminder Script	D1e SCRIPT FOR REMINDER TELEPHONE CALL.doc	05/17/2012

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