Information Collection

Att P_Initial Hospital Intake Questionnaire

IC 6666 under ICR 202407-0920-002 · OMB 0920-0212.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0212 Att P_Initial Hospital Intake Questionnaire	Form and Instruction
0920-0212 NHCS Initial Hospital Intake Questionnaire Att P - Initial Intake Questionnaire.docx	Form and Instruction
0920-0212 NHCS Initial Hospital Intake Questionnaire Att P - Initial Intake Questionnaire.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

0920-0212

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 and Instruction	0920-0212	NHCS Initial Hospital Intake Questionnaire	Att P - Initial Intake Questionnaire.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: 09-20-0167 Health Resources Utilization Statistics

FR Citation: 49 FR 37693

Number of Respondents: 123

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: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	123	-27	150
Annual IC Time Burden (Hours)	123	-13	136
Annual IC Cost Burden (Dollars)	0	0	0

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.