Information Collection

Initial Patient Information Form

IC 210978 under ICR 201602-0920-007 · OMB 0920-1019.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Initial Patient Information Form	Form
Initial Patient Information Att 6a_Initial patient information form.docx	Form
Att 6b_Initial Patient Info Form Instructions.docx Initial Patient Information Form Instructions	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	Initial Patient Information	Att 6a_Initial patient information 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)	1,000	1,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Initial Patient Information Form Instructions	Att 6b_Initial Patient Info Form Instructions.docx	02/17/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.