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Information Collection

Patient Demographic Information Form

IC 210977 under ICR 201602-0920-007 · OMB 0920-1019.

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Information Collection (IC) Details

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Patient Demographic Information Form
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form none Patient Demographic Information Att 5_Patient Demo Info Form.docx No   Paper Only

Health Health Care Services

 

10 0
   
Private Sector Businesses or other for-profits
 
   0 %

  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 1,000 0 0 0 0 1,000
Annual IC Time Burden (Hours) 83 0 0 0 0 83
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Information sheet - English Att 9a_information form.docx 02/11/2016
Information Sheet - Spanish Att 9b_information form_spanish.docx 02/11/2016
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.