OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Provider and Patient Interview

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

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
IC Document
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Provider and Patient Interview
 
Unchanged
 
Voluntary
 

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

Health Health Care Services

 

13 0
   
Individuals or Households
 
   50 %

  Requested 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 13 0 0 0 0 13
Annual IC Time Burden (Hours) 13 0 0 0 0 13
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.