Information Collection

Patient Quarterly Assessment

IC 263489 under ICR 202510-0920-002 · OMB 0920-1428.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1428 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Patient Quarterly Assessment	Form and Instruction
Att 4d_Patient Quarterly Assessment English Patient Quarterly Assessment	Form and Instruction
Att 4d_Patient Quarterly Assessment Spanish Patient Quarterly Assessment	Form and Instruction
Form 0920-1428 Patient Quarterly Assessment-English_02OCT2025 Patient Quarterly Assessment	Form and Instruction
Form 0920-1428 Patient Quarterly Assessment-Spanish_02OCT2025 Patient Quarterly Assessment	Form and Instruction
Att 4d_Patient Quarterly Assessment English Att 4d_Patient Quarterly Assessment English_CLEAN.docx	Form and Instruction
Att 4d_Patient Quarterly Assessment English Att 4d_Patient Quarterly Assessment English_CLEAN.docx	Form and Instruction
Att 4d_Patient Quarterly Assessment Spanish Att 4d_Patient Quarterly Assessment Spanish_CLEAN.docx	Form and Instruction
Att 4d_Patient Quarterly Assessment Spanish Att 4d_Patient Quarterly Assessment Spanish_CLEAN.docx	Form and Instruction
0920-1428 Patient Quarterly Assessment-English_02OCT2025 Att 4d_Patient Quarterly Assessment English_CLEAN.docx	Form and Instruction
0920-1428 Patient Quarterly Assessment-English_02OCT2025 Att 4d_Patient Quarterly Assessment English_CLEAN.docx	Form and Instruction
0920-1428 Patient Quarterly Assessment-Spanish_02OCT2025 Att 4d_Patient Quarterly Assessment Spanish_CLEAN.docx	Form and Instruction
0920-1428 Patient Quarterly Assessment-Spanish_02OCT2025 Att 4d_Patient Quarterly Assessment Spanish_CLEAN.docx	Form and Instruction

IC Title:

Patient Quarterly Assessment

Agency IC Tracking Number:

0920-1428-24DB

Is this a Common Form? Yes

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	n/a		Yes	Yes	Fillable Fileable
Form and Instruction	n/a		Yes	Yes	Fillable Fileable
Form and Instruction	0920-1428	N/A	Yes	Yes	Fillable Fileable
Form and Instruction	0920-1428	N/A	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 134

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	402	402
Annual IC Time Burden (Hours)	302	302
Annual IC Cost Burden (Dollars)	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.

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