Information Collection

Patient Information Form (PIF)

IC 192452 under ICR 202112-0920-006 · OMB 0920-0852.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0852 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Patient Information Form (PIF)	Form
Patient Information Attachment_D_PIF.docx	Form
Patient Information Attachment_D_PIF.docx	Form

IC Title:

Patient Information Form (PIF)

Agency IC Tracking Number:

0920-0852

Is this a Common Form? No

IC Status: Modified

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	none	Patient Information	Attachment_D_PIF.docx		Yes	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	6,300	6,300
Annual IC Time Burden (Hours)	1,785	1,785
Annual IC Cost Burden (Dollars)	63,118	63,118

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.