Information Collection

Patient Demographic Information Form

IC 210977 under ICR 201403-0920-016 · OMB 0920-1019.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.