Information Collection

Patient Baseline

IC 263488 under ICR 202602-0920-002 · OMB 0920-1428.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-26-0026 Patient Baseline Assessment English Patient Baseline	Form and Instruction
Form 0920-26-0026 Patient Baseline Assessment Spanish Patient Baseline	Form and Instruction
0920-26-0026 Patient Baseline Assessment English Att 4c_Patient Baseline Assessment English_Clean.docx	Form and Instruction
0920-26-0026 Patient Baseline Assessment Spanish Att 4c_Patient Baseline Assessment Spanish_Clean.docx	Form and Instruction

IC Title:

Patient Baseline

Agency IC Tracking Number:

0920-26-0026

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.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-26-0026				Yes	Yes	Fillable Fileable
Form and Instruction	0920-26-0026				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

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	134	134
Annual IC Time Burden (Hours)	101	101
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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