Patient Screening Form

Health Center Patient Survey

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0368 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Patient Screening Form Form
1 Patient Screener Patient Screening Form41913.doc Form
Recruitment Script_At Clinic.docx Recruitment Script_At Clinic IC Document
Flyer.doc Flyer IC Document
Handout_English.doc Handout_English IC Document

Information Collection (IC) Details

IC Title:	Patient Screening Form	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	1	Patient Screener	Patient Screening Form41913.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 92	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	92	92
Annual IC Time Burden (Hours)	9	9
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Recruitment Script_At Clinic	Recruitment Script_At Clinic.docx	05/09/2013
Flyer	Flyer.doc	05/09/2013
Handout_English	Handout_English.doc	05/09/2013

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