Information Collection

Prescreening Questionnaire for Patients and Care Partners (Spanish)

IC 248131 under ICR 202103-0955-002 · OMB 0955-0021.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form B3 Prescreening Questionnaire for Patients and Care Partners (Spanish)	Form
B3 Prescreening Questionnaire for Patients and Care Partner Attachment B3. Final Prescreening Questionnaire-Patients and Care Partners (Spanish).docx	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	B3	Prescreening Questionnaire for Patients and Care Partners (Spanish)	Attachment B3. Final Prescreening Questionnaire-Patients and Care Partners (Spanish).docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 75

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	75	75
Annual IC Time Burden (Hours)	6	6
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.