Patient Navigator ultural Competency Checklist

Patient Navigator Outreach and Chronic Disease Prevention Demonstration Program

Documents and Forms

Document Name Document Type
Form 10 Patient Navigator ultural Competency Checklist Form and Instruction
10 Cultural Competency HRSA_Patient_Navigator_Demonstration_Program_Cultural_Competency_Checklist.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Patient Navigator ultural Competency Checklist	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 and Instruction	10	Cultural Competency	HRSA_Patient_Navigator_Demonstration_Program_Cultural_Competency_Checklist.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 %

	Approved	Previously Approved
Annual Number of Responses for this IC	46	46
Annual IC Time Burden (Hours)	54	54
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.