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Federal forms, ICRs, and supporting documents

Information Collection

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

IC 212919 under ICR 201409-2900-004 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form 10-10137
HEALTH CARE EXPERIENCES OF PATIENTS WITH CONGESTIVE HEART FAILURE; NEEDS ASSESSMENT FOR CLINICAL INNOVATIONS–PACT DEMO LAB VISN20		 Form and Instruction
10-10137 C. HEALTH CARE EXPERIENCES OF PATIENTS WITH CONGESTIVE H
10-10137 S3 VISN 20 chf patients Interview Guide_rev11-10-2014.docx 		Form and Instruction

Information Collection (IC) Details

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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 10-10137 C. HEALTH CARE EXPERIENCES OF PATIENTS WITH CONGESTIVE HEART FAILURE; NEEDS ASSESSMENT FOR CLINICAL INNOVATIONS–PACT DEMO LAB VISN20 10-10137 S3 VISN 20 chf patients Interview Guide_rev11-10-2014.docx No   Paper Only

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Requested 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 80 0 80 0 0 0
Annual IC Time Burden (Hours) 100 0 100 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.