Patient Medical Record and Clinic Data

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⚠️ Notice: This information collection may be referencing outdated material.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 8 Patient Medical Record and Clinic Data Form and Instruction
8 Clinical Measures HRSA Patient Navigator Demonstration Program Clinical Measures Lab Tests.doc Form and Instruction
7 Co-occuring Disorders HRSA Patient Navigator Demonstration Program Co occurring Disorders.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Patient Medical Record and Clinic Data	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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	8	Clinical Measures	HRSA Patient Navigator Demonstration Program Clinical Measures Lab Tests.doc		Yes	Yes	Fillable Printable
Form and Instruction	7	Co-occuring Disorders	HRSA Patient Navigator Demonstration Program Co occurring Disorders.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

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

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,827	4,827
Annual IC Time Burden (Hours)	821	821
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.