Information Collection

Initial Patient Information Form

IC 210978 under ICR 201505-0920-005 · 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⚠️ Notice: This information collection may be referencing outdated material.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 6b_Initial Patient Information Form Instructions 13XA.docx	Instruction
Att 6a_Initial Patient Information form.docx	Other-WORD

IC Title:

Initial Patient Information Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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
Instruction			Att 6b_Initial Patient Information Form Instructions 13XA.docx		No	No	Printable Only
Other-WORD			Att 6a_Initial Patient 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	Previously Approved
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	1,000	1,000
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.