Information Collection

Patient Behavior Screener (for English, Spanish & Creole)

IC 209261 under ICR 201311-0920-006 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Patient Behavior Screener (for English, Spanish & Creole)	Form and Instruction
Appendix 6: Patient Behavior Screener (Creole) App 6 Patient beh screener (Creole).docx	Form and Instruction
Appendix 4: Patient Behavior Screener (English) App 4 Patient beh screener (English).docx	Form and Instruction
Appendix 5: Patient Behavior Screener (Spanish) App 5 Patient beh screener (Spanish).docx	Form and Instruction

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	None	Appendix 6: Patient Behavior Screener (Creole)	App 6 Patient beh screener (Creole).docx	Yes	No	Paper Only
Form and Instruction	None	Appendix 4: Patient Behavior Screener (English)	App 4 Patient beh screener (English).docx	Yes	No	Paper Only
Form and Instruction	None	Appendix 5: Patient Behavior Screener (Spanish)	App 5 Patient beh screener (Spanish).docx	Yes	No	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 6,315

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	25,260	25,260
Annual IC Time Burden (Hours)	2,105	2,105
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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