Information Collection

Patient Short interview

IC 178498 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⚠️ Notice: This information collection may be referencing outdated material.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 2b Patient Short interview Form and Instruction
2b 2012 Short Interview Questionnaire for Medical Monitorin Att_2b short interview v8 1 1.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Patient Short 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 and Instruction	2b	2012 Short Interview Questionnaire for Medical Monitoring Project (MMP)	Att_2b short interview v8 1 1.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 301	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	301	2	299
Annual IC Time Burden (Hours)	100	0	100
Annual IC Cost Burden (Dollars)	0	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.