Information Collection

Pain Management ECHO Evaluation: Patient Perspective

IC 230867 under ICR 201710-2900-001 · OMB 2900-0770.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0770 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Echo Interview Guide with cover.docx	Other-Telephone Evaluation
Generice Submission_Pain Management ECHO Evaluation.doc Generic Request_Pain Management ECHO Evaluation: Patient Perspective	IC Document
Patient Interview Invitation Letter.docx Invitation Letter	IC Document
Patient Information Sheet.docx Patient Information Sheet	IC Document

IC Title:

Pain Management ECHO Evaluation: Patient Perspective

Agency IC Tracking Number:

2900-0770

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
Other-Telephone Evaluation			Echo Interview Guide with cover.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 30

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	23	23
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Generic Request_Pain Management ECHO Evaluation: Patient Perspective	Generice Submission_Pain Management ECHO Evaluation.doc	04/16/2018
Invitation Letter	Patient Interview Invitation Letter.docx	04/12/2018
Patient Information Sheet	Patient Information Sheet.docx	04/16/2018

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