Patient Demographic Information Form

Integrating Community Pharmacists and Clinical Sites for Patient-Centered HIV Care

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1019 can be found here:

Documents and Forms

Document Name Document Type
Att 5_Patient Demographic Information form.docx Other-WORD
Att 9a_Consent form_english.docx Att 9a_Consent form_english IC Document
Att 9b_Consent form_spanish.docx Att 9b_Consent form_spanish IC Document

Information Collection (IC) Details

IC Title:	Patient Demographic Information Form	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
Other-WORD			Att 5_Patient Demographic Information form.docx		No	No	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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)	83	83
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att 9a_Consent form_english	Att 9a_Consent form_english.docx	03/25/2014
Att 9b_Consent form_spanish	Att 9b_Consent form_spanish.docx	03/25/2014

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