Information Collection

Patient Semi-Structured Interviews

IC 205427 under ICR 201301-0935-001 · OMB 0935-0208.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #4 Patient Semi-Structured Interviews	Form and Instruction
Form #4 Patient Interview Guide Attachment F -- Patient Interview Guide.doc	Form and Instruction
Attachment M -- Consent Form to Participate in Patient Interview.docx Attachment M -- Consent Form to Participate in Patient Interview	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	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form #4	Patient Interview Guide	Attachment F -- Patient Interview Guide.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 64

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	64	64
Annual IC Time Burden (Hours)	64	64
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment M -- Consent Form to Participate in Patient Interview	Attachment M -- Consent Form to Participate in Patient Interview.docx	01/11/2013

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