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Federal forms, ICRs, and supporting documents

Information Collection

Patient Information Form (PIF)

IC 192452 under ICR 202207-0920-011 · OMB 0920-0852.

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Information Collection (IC) Details

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Patient Information Form (PIF) 0920-0852
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form None Patient Information Form (PIF) (modified August 2022) Att_D_PIF_Aug22.docx Yes No Paper Only

Health Public Health Monitoring

 

100 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   0 %

  Approved 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 6,300 0 0 0 0 6,300
Annual IC Time Burden (Hours) 1,785 0 0 0 0 1,785
Annual IC Cost Burden (Dollars) 63,118 0 0 0 0 63,118

Title Document Date Uploaded
Patient Information Form (PIF) (August 2022 changes in tracked-change format) Att_D_PIF_tracked_Aug22.docx 08/02/2022
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.