Information Collection

Patient Medical Record and Clini Data

IC 198108 under ICR 201206-0915-006 · OMB 0915-0346.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 8 Patient Medical Record and Clini Data	Form and Instruction
8 Clinical Measures HRSA_Patient_Navigator_Demonstration_Program_Clinical_Measures_Lab_Tests.doc	Form and Instruction
7 Co-Occuring Disorders HRSA_Patient_Navigator_Demonstration_Program_Co_occurring_Disorders.doc	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	8	Clinical Measures	HRSA_Patient_Navigator_Demonstration_Program_Clinical_Measures_Lab_Tests.doc		Yes	Yes	Fillable Printable
Form and Instruction	7	Co-Occuring Disorders	HRSA_Patient_Navigator_Demonstration_Program_Co_occurring_Disorders.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	4,827	4,827
Annual IC Time Burden (Hours)	821	821
Annual IC Cost Burden (Dollars)	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.