Information Collection

Post-discharge Patient Questionnaire

IC 238230 under ICR 201910-0920-007 · OMB 0920-1285.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Post-discharge Patient Questionnaire	Form
Post-discharge patient questionnaire Attachment E2 Post-Discharge_Questionnaire.docx	Form
Attachment I2 Post-Discharge Patient Questionnaire Screen Print.pdf Post-discharge patient 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	Post-discharge patient questionnaire	Attachment E2 Post-Discharge_Questionnaire.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

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	2,400	2,400
Annual IC Time Burden (Hours)	400	400
Annual IC Cost Burden (Dollars)	9,355	9,355

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Post-discharge patient questionnaire - screenshots	Attachment I2 Post-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.