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Intake Questionnaire HELP
Patient Centered Care Collaboration to Improve Minority Health Project
OMB: 0990-0402
IC ID: 200847
OMB.report
HHS/HHSDM
OMB 0990-0402
ICR 201207-0990-005
IC 200847
( )
Documents and Forms
Document Name
Document Type
0990-PCCC_INTAKE QUESTIONNAIRE.docx
Other-questionnaire
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Intake Questionnaire HELP
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Removed
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-questionnaire
0990-PCCC_INTAKE QUESTIONNAIRE.docx
No
No
Printable Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Illness Prevention
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
50
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
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
0
0
0
0
0
0
Annual IC Time Burden (Hours)
0
0
0
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.