Information Collection

Providing Primary Care and Preventive Medical Services in Ryan White Funded Medical Care Settings

IC 218134 under ICR 201509-0906-001 · OMB 0906-0018.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Providing Primary Care and Preventive Medical Services in Ryan White Funded Medical Care Settings	Form and Instruction
1 Clinic Director Survey A_Clinic Director Survey.doc	Form and Instruction
2 Clinical Survey B_Clinician Survey.docx	Form and Instruction
3 Primary Care Data Extraction Template C_Primary Care Data Extraction Template.docx	Form and Instruction
4 Medical Director Interview Guide D_Medical Director Interview Guide.docx	Form and Instruction

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Clinic Director Survey	A_Clinic Director Survey.doc	Yes	Yes	Fillable Fileable
Form and Instruction	2	Clinical Survey	B_Clinician Survey.docx	Yes	Yes	Fillable Fileable
Form and Instruction	3	Primary Care Data Extraction Template	C_Primary Care Data Extraction Template.docx	Yes	Yes	Fillable Fileable
Form and Instruction	4	Medical Director Interview Guide	D_Medical Director Interview Guide.docx	Yes	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 280

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	280	280
Annual IC Time Burden (Hours)	245	245
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.