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Annual Clinic-Wide Clinical Performance Mearsures Report
Patient Navigator Outreach and Chronic Disease Prevention Demonstration Program
OMB: 0915-0346
IC ID: 198109
OMB.report
HHS/HSA
OMB 0915-0346
ICR 201206-0915-006
IC 198109
( )
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
Federal Enterprise Architecture Business Reference Module
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
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
5
0
0
0
0
5
Annual IC Time Burden (Hours)
40
0
0
0
0
40
Annual IC Cost Burden (Dollars)
0
0
0
0
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.
