Information Collection

Pre-discharge patient questionnaire

IC 238229 under ICR 201910-0920-007 · OMB 0920-1285.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Pre-discharge patient questionnaire	Form
Pre-discharge questionnaire Attachment E1 Pre-discharge_Questionnaire.docx	Form
Attachment I1 Pre-Discharge Patient Questionnaire Screen Print.pdf Pre-discharge questionnaire - screenshots	IC Document

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	none	Pre-discharge questionnaire	Attachment E1 Pre-discharge_Questionnaire.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: Epidemiolgic Studies and Suveillance of Disease Problems

FR Citation: 51 FR 226

Number of Respondents: 800

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	800	800
Annual IC Time Burden (Hours)	133	133
Annual IC Cost Burden (Dollars)	3,112	3,112

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Pre-discharge questionnaire - screenshots	Attachment I1 Pre-Discharge Patient Questionnaire Screen Print.pdf	10/22/2019

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