Quarterly Patient Information Form

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

OMB: 0920-1019

IC ID: 210979

Information Collection (IC) Details

View Information Collection (IC)

Quarterly Patient Information Form
 
No Unchanged
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Instruction Att 7b_Quarterly Patient Information Form Instructions 13XA.docx No No Printable Only
Other-WORD Att 7a_Quarterly patient 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 4,000 0 0 0 0 4,000
Annual IC Time Burden (Hours) 2,000 0 0 0 0 2,000
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.

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