Information Collection

Chicago-Participants, Implementation Staff, Local Hub Members

IC 203038 under ICR 201207-0990-005 · OMB 0990-0402.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment_3B-0990-PatientCentered.docx	Other-questionnaire
Attachment_3C-0990-PatientCentered.docx	Other-questions
Attachment_3D-0990-PatientCentered.docx	Other-questions
Attachment_3F-0990-PatientCentered.docx	Other-survey
Attachment_3G-0990-PatientCentered.docx	Other-questions
Attachment_3A patient centered care OMB commentsREVClean.docx	Other-Survey
Attachment_3E OMB commentsREVclean.docx	Other-Questions

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-questionnaire	Attachment_3B-0990-PatientCentered.docx	Yes	No	Printable Only
Other-questions	Attachment_3C-0990-PatientCentered.docx	No	No	Printable Only
Other-questions	Attachment_3D-0990-PatientCentered.docx	No	No	Printable Only
Other-survey	Attachment_3F-0990-PatientCentered.docx	No	No	Printable Only
Other-questions	Attachment_3G-0990-PatientCentered.docx	No	No	Printable Only
Other-Survey	Attachment_3A patient centered care OMB commentsREVClean.docx	No		Printable Only
Other-Questions	Attachment_3E OMB commentsREVclean.docx	No		Printable Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 459

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	459	459
Annual IC Time Burden (Hours)	247	247
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.