Prescreening Questionnaire for Clinicians and Healthcare Professionals

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

OMB: 0955-0021

IC ID: 247983

Information Collection (IC) Details

View Information Collection (IC)

Prescreening Questionnaire for Clinicians and Healthcare Professionals
 
No New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form B1 Prescreening Questionnaire for Clinicians and Healthcare Professionals Attachment B1. Final Prescreening Questionnaire-Clinicians and Healthcare Professionals .docx Yes Yes Fillable Printable

Health Health Care Services

 

750 0
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   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 750 0 750 0 0 0
Annual IC Time Burden (Hours) 63 0 63 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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