Patient Pilot Study Screener - Intervention Screener

Develop and Implement UCARE4LIFE Message Library

Documents and Forms

Document Name Document Type
Form 1 Patient Pilot Study Screener - Intervention Screener Form and Instruction
1 Survey Screener 3 AppendixE_SurveyScreener.doc Form and Instruction
3 AppendixD_SurveyRecruitmentFlyer.pub 3 AppendixD_SurveyRecruitmentFlyer IC Document

Information Collection (IC) Details

IC Title:	Patient Pilot Study Screener - Intervention Screener	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	1	Survey Screener	3 AppendixE_SurveyScreener.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,000	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	1,000	1,000
Annual IC Time Burden (Hours)	250	250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
3 AppendixD_SurveyRecruitmentFlyer	3 AppendixD_SurveyRecruitmentFlyer.pub	08/30/2013

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