Information Collection

Three-Month Patient Follow-up Questionnaire

IC 210533 under ICR 201402-0935-002 · OMB 0935-0217.

Documents and Forms

Documents and forms in this information collection
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

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	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 %

table that charts list of burden
	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

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.