Patient Navigator Survey

Patient Navigator Outreach and Chronic Disease Prevention Demonstration Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0346 can be found here:

Documents and Forms

Document Name Document Type
Form 3 Patient Navigator Survey Form and Instruction
3 Patient Navigator Survey HRSA Patient Navigator Demonstration Program Navigator Form.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Patient Navigator Survey	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	3	Patient Navigator Survey	HRSA Patient Navigator Demonstration Program Navigator Form.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 46	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	46	46
Annual IC Time Burden (Hours)	9	9
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.