Information Collection

Phase II Interview for Participants of Patient-level Intervention

IC 249796 under ICR 202109-0920-005 · OMB 0920-1361.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Phase II Interview for Participants of Patient-level Intervention	Form and Instruction
Phase II Interview Att 10_Phase II interview.docx	Form and Instruction
Phase II Interview Att 10_Phase II interview.docx	Form and Instruction
Referral Script Att 11_Referral script.docx	Form and Instruction
Referral Script Att 11_Referral script.docx	Form and Instruction

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 and Instruction	n/a	Phase II Interview	Att 10_Phase II interview.docx		Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Referral Script	Att 11_Referral script.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: Epidemiologic Studies and Surveillance of Disease Problems:(SORN) 09-20-0136

FR Citation: 57 FR 62812

Number of Respondents: 33

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	33	33
Annual IC Time Burden (Hours)	17	17
Annual IC Cost Burden (Dollars)	359	359

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.