OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Destination of Released Patients Following Treatment with Iodine-131 and Estimation of Doses to Members of the Public at Locations Other Than Conventional Residences Receiving Such Patients

IC 218337 under ICR 201509-3150-004 · OMB 3150-0232.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Hotel -Nursing Home Survey.docx Other-Survey
Treating institutions survey.pdf Other-Survey
ThyCa Survey.docx Other-Survey
Patient Telephone Interview Script.docx Other-Telephone Survey
Survey Reminder Telephone Script for Patients.docx Other-Telephone survey reminder

Information Collection (IC) Details

View Information Collection (IC)

layout table

Information Collection Instruments:
table that charts list of instruments
Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Survey Treating institutions survey.pdf No   Paper Only
Other-Telephone survey reminder Survey Reminder Telephone Script for Patients.docx No   Paper Only
Other-Survey Hotel -Nursing Home Survey.docx No   Paper Only
Other-Telephone Survey Patient Telephone Interview Script.docx No   Paper Only
Other-Survey ThyCa Survey.docx Yes Yes Fillable Fileable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  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 5,175 0 5,175 0 0 0
Annual IC Time Burden (Hours) 1,675 0 1,675 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 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.