Information Collection

Patient Interviews

IC 206890 under ICR 201305-0935-001 · OMB 0935-0212.

Documents and Forms

Document Name Document Type
Form Form #7 Patient Interviews Form and Instruction
Form #7 Patient Interview Guide Attachment J -- Patient Interivew Guide.docx Form and Instruction
Attachment R -- Information Sheet for Patient Interviews and Observations.docx Attachment R -- Information Sheet for Patient Interviews and Observations IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Patient Interviews	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 #7	Patient Interview Guide	Attachment J -- Patient Interivew Guide.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 36	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	36	36
Annual IC Time Burden (Hours)	18	18
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment R -- Information Sheet for Patient Interviews and Observations	Attachment R -- Information Sheet for Patient Interviews and Observations.docx	05/07/2013

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