Information Collection

Att E_Patient Information Form (PIF)

IC 192452 under ICR 201612-0920-005 · OMB 0920-0852.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0852 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Phase 4_PIF_201412 Att E_Patient Information Form (PIF)	Form
Phase 4_PIF_201412 Patient Information Form (PIF) Att E - PIF.pdf	Form
Att G - AUF and HAIF.pdf Att G_ Antimicrobial Use Form	IC Document
Att J - EIP HFA.pdf Att J_EIP Healthcare Facility Assessment	IC Document
Att K - AQUA Forms.pdf Att K_Antimicrobial Quality Assessment (AQUA) Form 1	IC Document

IC Title:

Att E_Patient Information Form (PIF)

Agency IC Tracking Number:

0920-0852

Is this a Common Form? No

IC Status: Unchanged

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	Phase 4_PIF_20141218	Patient Information Form (PIF)	Att E - PIF.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	6,300	6,300
Annual IC Time Burden (Hours)	1,785	1,785
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att G_ Antimicrobial Use Form	Att G - AUF and HAIF.pdf	09/19/2016
Att J_EIP Healthcare Facility Assessment	Att J - EIP HFA.pdf	09/19/2016
Att K_Antimicrobial Quality Assessment (AQUA) Form 1	Att K - AQUA Forms.pdf	09/19/2016

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