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Quarterly Report
Patient Navigator Outreach and Chronic Disease Prevention Demonstration Program
OMB: 0915-0346
IC ID: 198114
OMB.report
HHS/HSA
OMB 0915-0346
ICR 201106-0915-002
IC 198114
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0346 can be found here:
2012-06-26 - Revision of a currently approved collection
2011-12-19 - New collection (Request for a new OMB Control Number)
Documents and Forms
Document Name
Document Type
Form 14
Quarterly Report
Form and Instruction
14 Quarterly_Report
HRSA Patient Navigator Demonstration Program Quarterly Report Form.doc
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Quarterly Report
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
14
Quarterly_Report
HRSA Patient Navigator Demonstration Program Quarterly Report Form.doc
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
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 New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
40
0
40
0
0
0
Annual IC Time Burden (Hours)
40
0
40
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
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.