Information Collection

Annual Clinic-Wide Clinical Performance Mearsures Report

IC 198109 under ICR 201206-0915-006 · OMB 0915-0346.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 9 Annual Clinic-Wide Clinical Performance Mearsures Report	Form
9 Clinic-Wide Measures HRSA_Patient_Navigator_Demonstration_Program_Clinicwide_Measures_Form.doc	Form

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	9	Clinic-Wide Measures	HRSA_Patient_Navigator_Demonstration_Program_Clinicwide_Measures_Form.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5

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	5	5
Annual IC Time Burden (Hours)	40	40
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.