Information Collection

Phase II Interview for Participants of Patient-level Intervention

IC 249796 under ICR 202109-0920-005 · OMB 0920-1361.

Documents and Forms

Document Name Document Type
Phase II Interview for Participants of Patient-level Intervention Form and Instruction
Phase II Interview Att 10_Phase II interview.docx Form and Instruction
Phase II Interview Att 10_Phase II interview.docx Form and Instruction
Referral Script Att 11_Referral script.docx Form and Instruction
Referral Script Att 11_Referral script.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Phase II Interview for Participants of Patient-level Intervention	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	n/a	Phase II Interview	Att 10_Phase II interview.docx		Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Referral Script	Att 11_Referral script.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: Epidemiologic Studies and Surveillance of Disease Problems:(SORN) 09-20-0136	FR Citation: 57 FR 62812

Number of Respondents: 33	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
Annual Number of Responses for this IC	33	33
Annual IC Time Burden (Hours)	17	17
Annual IC Cost Burden (Dollars)	359	359

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.