Post-discharge Patient Questionnaire

Evaluating the implementation and impact of an opioid medication management program, in a hospital discharge setting, to reduce falls in older adults

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Post-discharge Patient Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection 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 %

	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

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.