Quarterly Patient Information Form

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1019 can be found here:

Documents and Forms

Document Name Document Type
Att 7b_Quarterly Patient Information Form Instructions 13XA.docx Instruction
Att 7a_Quarterly Patient Info Form.docx Other-WORD
Screenshots for att 7a_Quarterly Patient Info form.pdf Other-Screenshots
Change Request Justification.docx Request for Change Justification IC Document

Information Collection (IC) Details

IC Title:	Quarterly Patient Information Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Instrument File	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 Info Form.docx	Yes	Yes	Fillable Fileable
Other-Screenshots	Screenshots for att 7a_Quarterly Patient Info form.pdf	Yes	Yes	Fillable Fileable

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: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	4,000	4,000
Annual IC Time Burden (Hours)	2,000	2,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Request for Change Justification	Change Request Justification.docx	09/29/2015

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.