Grantee Health Care Provider Focus Group

Patient Navigator Outreach and Chronic Disease Prevention Demonstration Program

Documents and Forms

Document Name Document Type
Form 15 Grantee Health Care Provider Focus Group Form and Instruction
15 Participant Information Form PARTICIPANT_INFORMATION_FORM.doc Form and Instruction
14 Consent Form Consent_for_PNDP_Discussion_Questions_3-7-11_doc.doc Form and Instruction
12 Focus_Group_Health_Provider PNDP2_FocusGroup_HealthCareProv.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Grantee Health Care Provider Focus Group	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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	15	Participant Information Form	PARTICIPANT_INFORMATION_FORM.doc	Yes	No	Printable Only
Form and Instruction	14	Consent Form	Consent_for_PNDP_Discussion_Questions_3-7-11_doc.doc	Yes	No	Printable Only
Form and Instruction	12	Focus_Group_Health_Provider	PNDP2_FocusGroup_HealthCareProv.doc	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 30	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	30	30
Annual IC Time Burden (Hours)	30	30
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.