Information Collection

Promoting Patient Engagement in Clinical Preventive Services

IC 229946 under ICR 201509-0990-002 · OMB 0990-0281.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0281 can be found here:

Documents and Forms

Document Name Document Type
Att-A_OMB_hf_Outcomes_FY18_2018.02.01.docx Other-Patient Survey
Att-B_OMB_hf_Outcomes_FY18_2018.02.01.docx Other-interview telephone/internet
Supporting-Statement-B_OMB_hf_Outcomes_FY18_2017.02.01.docx SS_B IC Document
Promoting Patient Engagement in Clinical Preventive ServicesSupporting-Statement-A.docx SS_A IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Promoting Patient Engagement in Clinical Preventive Services	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Patient Survey			Att-A_OMB_hf_Outcomes_FY18_2018.02.01.docx		Yes	Yes	Fillable Printable
Other-interview telephone/internet			Att-B_OMB_hf_Outcomes_FY18_2018.02.01.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 820	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	820	820
Annual IC Time Burden (Hours)	117	117
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SS_B	Supporting-Statement-B_OMB_hf_Outcomes_FY18_2017.02.01.docx	02/06/2018
SS_A	Promoting Patient Engagement in Clinical Preventive ServicesSupporting-Statement-A.docx	02/06/2018

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