Information Collection

Post-discharge Hospital Patients with MRSA (Case Patients) - Screening and Consent Process

IC 205888 under ICR 201302-0920-016 · OMB 0920-0958.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment F-Screening questions HACO_revised 3_cleaned.docx	Instruction
Attachment E - Verbal Consent.revised docx.docx Attachment E - Verbal Consent.revised docx	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
Instruction			Attachment F-Screening questions HACO_revised 3_cleaned.docx		Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 150

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	150	150
Annual IC Time Burden (Hours)	13	13
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment E - Verbal Consent.revised docx	Attachment E - Verbal Consent.revised docx.docx	02/14/2013

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