Information Collection

Prescreening Questionnaire for Patients and Care Partners

IC 246469 under ICR 202103-0955-002 · OMB 0955-0021.

Documents and Forms

Document Name Document Type
Form B2 Prescreening Questionnaire for Patients and Care Partners Form
B2 Patients and Care Partners Prescreening Questionnaire Attachment B2. Final Prescreening Questionnaire-Patients and Care Partners (English).docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Prescreening Questionnaire for Patients and Care Partners	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	B2	Patients and Care Partners Prescreening Questionnaire	Attachment B2. Final Prescreening Questionnaire-Patients and Care Partners (English).docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 675	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	675	675
Annual IC Time Burden (Hours)	56	56
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.