Questionnaire for Other Patients who were receiving Dialysis at the same time of the Event

Undetermined Cause of Cardiac Arrest during Hemodialysis — Connecticut 2015-2016

Documents and Forms

Document Name Document Type
Questionnaire for Other Patients who were receiving Dialysis at the same time of the Event Form and Instruction
Questionnaire for Other Patients who were receiving Dial Att 4 - Other patient interview questions.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Questionnaire for Other Patients who were receiving Dialysis at the same time of the Event	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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NA	Questionnaire for Other Patients who were receiving Dialysis at the same time of the Event	Att 4 - Other patient interview questions.docx	NA	No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 62812

Number of Respondents: 40	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	20	20
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.