Prescreening Questionnaire for Patients and Care Partners

ACCESS, EXCHANGE, AND USE OF SOCIAL DETERMINANTS OF HEALTH DATA IN CLINICAL NOTES

OMB: 0955-0021

IC ID: 246469

Information Collection (IC) Details

View Information Collection (IC)

Prescreening Questionnaire for Patients and Care Partners
 
No New
 
Voluntary
 

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

Health Health Care Services

 

675 0
   
Individuals or Households
 
   100 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 675 0 675 0 0 0
Annual IC Time Burden (Hours) 56 0 56 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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