Three-Month Patient Follow-up Questionnaire

Pilot Test of an Emergency Department (ED) Discharge Tool

Documents and Forms

Document Name Document Type
Form 3 Three-Month Patient Follow-up Questionnaire Form and Instruction
3 Three-Month Patient Follow-up Questionnaire Attachment D - Three-Month Patient Follow-up Phone Call 2013.12.13.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Three-Month Patient Follow-up Questionnaire	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	3	Three-Month Patient Follow-up Questionnaire	Attachment D - Three-Month Patient Follow-up Phone Call 2013.12.13.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 180	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	180	180
Annual IC Time Burden (Hours)	15	15
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.