Information Collection

Parent - Children's Healthcare of Atlanta Patient History Questionnaire (in-depth evaluation)

IC 186660 under ICR 200809-0920-002 · OMB 0920-0799.

Documents and Forms

Document Name Document Type
Form No number Parent - Children's Healthcare of Atlanta Patient History Questionnaire (in-depth evaluation) Form
No number Children's Healthcare of Atlanta Patient History Questio Attachment AG.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Parent - Children's Healthcare of Atlanta Patient History Questionnaire (in-depth evaluation)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	No number	Children's Healthcare of Atlanta Patient History Questionnaire	Attachment AG.pdf		Yes	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 62812

Number of Respondents: 15	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	15	15
Annual IC Time Burden (Hours)	3	3
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.