Information Collection

Online Survey - 12 month Follow-Up - Patients 18 years or older

IC 225613 under ICR 201702-0920-003 · OMB 0920-1164.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Online Survey - 12 month Follow-Up - Patients 18 years or older	Form and Instruction
Onsline Survey - Patient 18 yr 12-month Follow-Up Englis Att R-3 Patient Survey_12 mo vB (Eng).docx	Form and Instruction
Onsline Survey - Patient 18 yr 12-month Follow-Up Spanis Att R-4_Screen shots_Patient Survey_12 mo vB (Span).pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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 and Instruction	NA	Onsline Survey - Patient 18 yr 12-month Follow-Up English	Att R-3 Patient Survey_12 mo vB (Eng).docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	NA	Onsline Survey - Patient 18 yr 12-month Follow-Up Spanish/Screenshot	Att R-4_Screen shots_Patient Survey_12 mo vB (Span).pdf	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0136, Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 534

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	534	534
Annual IC Time Burden (Hours)	89	89
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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