Information Collection

Patients Standard Interview

IC 178497 under ICR 201203-0920-011 · OMB 0920-0740.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0740 can be found here:

Documents and Forms

Document Name Document Type
Form 2a Patients Standard Interview Form
2a 2012 Standard Interview Questionnaire for Medical Monito Att_2a standard interview v8 3 1 b (2).docx Form
Attachment11_Model Scripts.doc Provider/Patient Model Scripts IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Patients Standard Interview	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	2a	2012 Standard Interview Questionnaire for Medical Monitoring Project (MMP)	Att_2a standard interview v8 3 1 b (2).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7,219	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	7,219	47	7,172
Annual IC Time Burden (Hours)	5,414	35	5,379
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Provider/Patient Model Scripts	Attachment11_Model Scripts.doc	03/12/2009

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.