Input Patient Data and Test Result Reporting - Long Term Program

SimpleReport Mobile Application

Documents and Forms

Document Name Document Type
Input Patient Data and Test Result Reporting - Long Term Program Form
SimpleReport Mobile Application SimpleReport Screenshot.PNG Form
SimpleReport Mobile Application SimpleReport Screenshot.PNG Form

Information Collection (IC) Details

IC Title:	Input Patient Data and Test Result Reporting - Long Term Program	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	NA	SimpleReport Mobile Application	SimpleReport Screenshot.PNG	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 250,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	250,000	250,000
Annual IC Time Burden (Hours)	25,000	25,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.