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Federal forms, ICRs, and supporting documents

Information Collection

Patient Screening: Short Blessed Scale

IC 239087 under ICR 202303-0915-004 · OMB 0915-0368.

Documents and Forms
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Document Type
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Information Collection (IC) Details

View Information Collection (IC)

Patient Screening: Short Blessed Scale
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form 3 Attachment 13 Short Blessed Scale Test_psg.docx Attachment 13 Short Blessed Scale Test_psg.docx Yes Yes Fillable Fileable
Form 3 C Attachment 13 Short Blessed Scale Exam_2019_CH_psg.docx Attachment 13 Short Blessed Scale Exam_2019_CH_psg.docx Yes Yes Fillable Fileable
Form 3 S Attachment 13 Short Blessed Scale (Spanish)_psg.docx Attachment 13 Short Blessed Scale (Spanish)_psg.docx Yes Yes Fillable Fileable
Form 3 V Attachment 13 Short Blessed Scale Exam 2023_VIE_psg.docx Attachment 13 Short Blessed Scale Exam 2019_VIE_psg.docx Yes Yes Fillable Fileable
Form 3 T Attachment 13 Short Blessed Scale Exam_Tagalog_psg.docx Attachment 13 Short Blessed Scale Exam_Tagalog_psg.docx Yes Yes Fillable Fileable

Health Health Care Services

 

18 0
   
Individuals or Households
 
   100 %

  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 18 0 0 0 0 18
Annual IC Time Burden (Hours) 1 0 0 0 0 1
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.