Patient/family /caregiver interviews

Adapting Best Practices for Medicaid Readmissions

Documents and Forms

Document Name Document Type
Form Form #3 Patient/family /caregiver interviews Form and Instruction
Form #3 Patient-Family-caregiver Interview Tool (Drivers) Attachment C -- Patient-Family-Caregiver Interview Tool (Drivers).doc Form and Instruction
Form #4 Patient-Family-Caregiver Interview Tool (Test Strategies Attachment D -- Patient-Family-Caregiver Interview Tool (Test Strategies).doc Form and Instruction

Information Collection (IC) Details

IC Title:	Patient/family /caregiver interviews	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

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	Form #3	Patient-Family-caregiver Interview Tool (Drivers)	Attachment C -- Patient-Family-Caregiver Interview Tool (Drivers).doc		Yes	Yes	Paper Only
Form and Instruction	Form #4	Patient-Family-Caregiver Interview Tool (Test Strategies)	Attachment D -- Patient-Family-Caregiver Interview Tool (Test Strategies).doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 240	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	960	960
Annual IC Time Burden (Hours)	320	320
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.