Screening Questionnaire

Patient Centered Care Collaboration to Improve Minority Health Project

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0402 can be found here:

Documents and Forms

Document Name Document Type
0990-PCOR-Screening-ChicagoSurveys-Dec8-11.doc Other-survey

Information Collection (IC) Details

IC Title:	Screening Questionnaire	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
Other-survey			0990-PCOR-Screening-ChicagoSurveys-Dec8-11.doc		No	No	Printable Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 165	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	165	165
Annual IC Time Burden (Hours)	14	14
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.