Information Collection

Annual Clinic-Wide Clinical Performance Mearsures Report

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Annual Clinic-Wide Clinical Performance Mearsures Report	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:

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 %

	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

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.