Information Collection

Patient Activation Measures Survey

IC 205428 under ICR 201301-0935-001 · OMB 0935-0208.

Documents and Forms

Document Name Document Type
Form Form #5 Patient Activation Measures Survey Form and Instruction
Form #5 Patient Activation Measures Survey Attachment G -- Patient Activation Measure Survey.doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Patient Activation Measures Survey	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 #5	Patient Activation Measures Survey	Attachment G -- Patient Activation Measure Survey.doc		Yes	Yes	Fillable Fileable

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 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	64	64
Annual IC Time Burden (Hours)	13	13
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.