Information Collection

Patient Information Form (PIF)

IC 192452 under ICR 201908-0920-006 · OMB 0920-0852.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0852 can be found here:

Documents and Forms

Document Name Document Type
Patient Information Form (PIF) Form
Patient Information Attachment_D_PIF_Final_Updated.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Patient Information Form (PIF)	Agency IC Tracking Number:	0920-0852

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	none	Patient Information	Attachment_D_PIF_Final_Updated.pdf		Yes	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	6,300	0	6,300
Annual IC Time Burden (Hours)	1,785	0	1,785
Annual IC Cost Burden (Dollars)	63,118	63,118	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.