Information Collection

Houston- Participant,Provider, Facility Administrator, Local Hub. Steering Committee Members

IC 203039 under ICR 201207-0990-005 · OMB 0990-0402.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment_5A-0990-PatientCentered.docx	Other-survey
Attachment_5B-0990-PatientCentered.docx	Other-survey
Attachment_5C-0990-PatientCentered.docx	Other-survey
Attachment_5D (2)0990-PatientCentered.docx	Other-survey
Attachment_5E-0990-PatientCentered.docx	Other-survey
Attachment_5G-0990-PatientCentered.docx	Other-survey
Attachment_5F-0990-PatientCentered.docx	Other-survey
Attachment_5H-0990-PatientCentered.docx	Other-survey
Attachment_5I-0990-PatientCentered.docx	Other-survey
Attachment_6A-0990-PatientCentered.docx Attachment_6A-0990-PatientCentered	IC Document
Attachment_8-0990-PatientCentered.docx Attachment_8-0990-PatientCentered	IC Document

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-survey	Attachment_5A-0990-PatientCentered.docx	No	No	Printable Only
Other-survey	Attachment_5B-0990-PatientCentered.docx	No	No	Printable Only
Other-survey	Attachment_5C-0990-PatientCentered.docx	No	No	Printable Only
Other-survey	Attachment_5D (2)0990-PatientCentered.docx	No	No	Printable Only
Other-survey	Attachment_5E-0990-PatientCentered.docx	No	No	Printable Only
Other-survey	Attachment_5G-0990-PatientCentered.docx	No	No	Printable Only
Other-survey	Attachment_5F-0990-PatientCentered.docx	No	No	Printable Only
Other-survey	Attachment_5H-0990-PatientCentered.docx	No	No	Printable Only
Other-survey	Attachment_5I-0990-PatientCentered.docx	No	No	Printable Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,125

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	1,125	1,125
Annual IC Time Burden (Hours)	555	555
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment_6A-0990-PatientCentered	Attachment_6A-0990-PatientCentered.docx	07/03/2012
Attachment_8-0990-PatientCentered	Attachment_8-0990-PatientCentered.docx	07/03/2012

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.