Patient Demographic Information Form

Integrating Community Pharmacists and Clinical Sites for Patient-Centered HIV Care

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Patient Demographic Information Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	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 %

	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

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.