Information Collection

Quarterly Patient Information Form

IC 210979 under ICR 201406-0920-009 · OMB 0920-1019.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1019 can be found here:

Documents and Forms

Document Name Document Type
Att 7b_Quarterly Patient Information Form Instructions 13XA.docx Instruction
Att 7a_Quarterly patient information form.docx Other-WORD

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Quarterly Patient Information Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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
Instruction			Att 7b_Quarterly Patient Information Form Instructions 13XA.docx		No	No	Printable Only
Other-WORD			Att 7a_Quarterly patient information form.docx		No	No	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	4,000	4,000
Annual IC Time Burden (Hours)	2,000	2,000
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.