Information Collection

Patient Demographic Information Form

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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Patient Demographic Information Form	Form
Patient Demographic Information Att 5_Patient Demo Info Form.docx	Form
Att 9a_information form.docx Information sheet - English	IC Document
Att 9b_information form_spanish.docx Information Sheet - Spanish	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

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
Form	none	Patient Demographic Information	Att 5_Patient Demo Info Form.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	83	83
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.