Information Collection

Provider and Patient Interview

IC 263759 under ICR 202401-0935-006 · OMB 0935-0124.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Provider and Patient Interview	Form and Instruction
1 Provider and Patient Interview Provider and Patient Interview.docx	Form and Instruction
1 Provider and Patient Interview Provider and Patient Interview.docx	Form and Instruction
eCarePlan Consent Information Sheet - INTERVIEW.docx eCarePlan Consent Information Sheet - INTERVIEW	IC Document
eCarePlan Consent Information Sheet - INTERVIEW.docx eCarePlan Consent Information Sheet - INTERVIEW	IC Document
fast-track-PRA-submission-short-form-3 Provider and Patient Interview.docx fast track PRA submission short form Provider and Patient Interview	IC Document
fast-track-PRA-submission-short-form-3 Provider and Patient Interview.docx fast track PRA submission short form Provider and Patient Interview	IC Document

IC Title:

Agency IC Tracking Number:

IC Status: Unchanged

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	1	Provider and Patient Interview	Provider and Patient Interview.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 13

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	13	13
Annual IC Time Burden (Hours)	13	13
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
eCarePlan Consent Information Sheet - INTERVIEW	eCarePlan Consent Information Sheet - INTERVIEW.docx	11/30/2023
fast track PRA submission short form Provider and Patient Interview	fast-track-PRA-submission-short-form-3 Provider and Patient Interview.docx	11/30/2023

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.