OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Patient Behavior Screener (for English, Spanish & Creole)

IC 209256 under ICR 201311-0920-005 · OMB 0920-1002.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Patient Behavior Screener (for English, Spanish & Creole)
 
No New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction None Appendix 6: Patient Behavior Screener (Creole) App 6 Patient beh screener (Creole).docx Yes No Paper Only
Form and Instruction None Appendix 4: Patient Behavior Screener (English) App 4 Patient beh screener (English).docx Yes No Paper Only
Form and Instruction None Appendix 5: Patient Behavior Screener (Spanish) App 5 Patient beh screener (Spanish).docx Yes No Paper Only

Health Consumer Health and Safety

 

6,315 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 25,260 0 25,260 0 0 0
Annual IC Time Burden (Hours) 2,105 0 2,105 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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