Patient Demographic Information Form

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

OMB: 0920-1019

IC ID: 210977

Information Collection (IC) Details

View Information Collection (IC)

Patient Demographic Information Form
 
No Unchanged
 
Voluntary
 

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

Health Illness Prevention

 

10 0
   
State, Local, and Tribal Governments
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 1,000 0 0 0 0 1,000
Annual IC Time Burden (Hours) 83 0 0 0 0 83
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.

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