Interviews with Clinicians and Office Staff

Patient-Reported Health Information Technology and Workflow

Documents and Forms

Document Name Document Type
Form Form #5 Interviews with Clinicians and Office Staff Form and Instruction
Form #5 Interview Guide for Clinicians and Office Staff Attachment G -- Interview Guide for Clinicians and Office Staff.docx Form and Instruction
Attachment P -- Information Sheet for Clinicians.docx Attachment P -- Information Sheet for Clinicians IC Document
Attachment Q -- Information Sheet for Office Staff.docx Attachment Q -- Information Sheet for Office Staff IC Document

Information Collection (IC) Details

IC Title:	Interviews with Clinicians and Office Staff	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	Interview Guide for Clinicians and Office Staff	Attachment G -- Interview Guide for Clinicians and Office Staff.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 114	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	114	114
Annual IC Time Burden (Hours)	114	114
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment P -- Information Sheet for Clinicians	Attachment P -- Information Sheet for Clinicians.docx	05/07/2013
Attachment Q -- Information Sheet for Office Staff	Attachment Q -- Information Sheet for Office Staff.docx	05/07/2013

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