Information Collection

Physician - Cognitive Testing Screener

IC 215712 under ICR 201503-0920-006 · OMB 0920-1063.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Physician - Cognitive Testing Screener	Form
Physician Cognitive Testing Screener Att 4b - Cog Testing Screener 022415.docx	Form

IC Title:

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	none	Physician Cognitive Testing Screener	Att 4b - Cog Testing Screener 022415.docx		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0167 Health Care Statistics

FR Citation: 49 FR 37697

Number of Respondents: 25

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

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	25	25
Annual IC Time Burden (Hours)	2	2
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.