Information Collection

Patient Screening: Short Blessed Scale

IC 239087 under ICR 202012-0915-002 · OMB 0915-0368.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0368 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3 Patient Screening: Short Blessed Scale	Form
3 Attachment 13 Short Blessed Scale Test_psg.docx Attachment 13 Short Blessed Scale Test_psg.docx	Form
3 C Attachment 13 Short Blessed Scale Exam_2019_CH_psg.docx Attachment 13 Short Blessed Scale Exam_2019_CH_psg.docx	Form
3 S Attachment 13 Short Blessed Scale (Spanish)_psg.docx Attachment 13 Short Blessed Scale (Spanish)_psg.docx	Form
3 V Attachment 13 Short Blessed Scale Exam 2019_VIE_psg.docx Attachment 13 Short Blessed Scale Exam 2019_VIE_psg.docx	Form
3 T Attachment 13 Short Blessed Scale Exam_Tagalog_psg.docx Attachment 13 Short Blessed Scale Exam_Tagalog_psg.docx	Form

IC Title:

Patient Screening: Short Blessed Scale

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	3	Attachment 13 Short Blessed Scale Test_psg.docx	Attachment 13 Short Blessed Scale Test_psg.docx	Yes	Yes	Fillable Fileable
Form	3 C	Attachment 13 Short Blessed Scale Exam_2019_CH_psg.docx	Attachment 13 Short Blessed Scale Exam_2019_CH_psg.docx	Yes	Yes	Fillable Fileable
Form	3 S	Attachment 13 Short Blessed Scale (Spanish)_psg.docx	Attachment 13 Short Blessed Scale (Spanish)_psg.docx	Yes	Yes	Fillable Fileable
Form	3 V	Attachment 13 Short Blessed Scale Exam 2019_VIE_psg.docx	Attachment 13 Short Blessed Scale Exam 2019_VIE_psg.docx	Yes	Yes	Fillable Fileable
Form	3 T	Attachment 13 Short Blessed Scale Exam_Tagalog_psg.docx	Attachment 13 Short Blessed Scale Exam_Tagalog_psg.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 18

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	Previously Approved
Annual Number of Responses for this IC	18	18
Annual IC Time Burden (Hours)	1	1
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.