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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Providing Primary Care and Preventive Medical Services in Ryan White Funded Medical Care Settings	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection 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 %

	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

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.