Information Collection

C. Health Care Experiences Of Patients With Congestive Heart Failure; Needs Assessment For Clinical Innovations–pact Demo Lab Visn20

IC 212918 under ICR 201409-2900-004 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10-10136 C. HEALTH CARE EXPERIENCES OF PATIENTS WITH CONGESTIVE HEART FAILURE; NEEDS ASSESSMENT FOR CLINICAL INNOVATIONS–PACT DEMO LAB VISN20	Form and Instruction
10-10136 CHF PATIENT INTERVIEW GUIDES: –PACT DEMO LAB VISN20 10-10136 S3 VISN 20 CHF patient interview guide 2_rev11-10-2014.docx	Form and Instruction

IC Title:

C. HEALTH CARE EXPERIENCES OF PATIENTS WITH CONGESTIVE HEART FAILURE; NEEDS ASSESSMENT FOR CLINICAL INNOVATIONSâPACT DEMO LAB VISN20

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	10-10136	CHF PATIENT INTERVIEW GUIDES: âPACT DEMO LAB VISN20	10-10136 S3 VISN 20 CHF patient interview guide 2_rev11-10-2014.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 380

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	380	380
Annual IC Time Burden (Hours)	343	343
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.