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Questionnaire for Patients who Suffered from Cardiac Arrest but Survived
Undetermined Cause of Cardiac Arrest during Hemodialysis — Connecticut 2015-2016
OMB: 0920-1095
IC ID: 219759
OMB.report
HHS/CDC
OMB 0920-1095
ICR 201601-0920-014
IC 219759
( )
Documents and Forms
Document Name
Document Type
Questionnaire for Patients who Suffered from Cardiac Arrest but Survived
Form and Instruction
Questionnaire for Patients who Suffered Cardiac Arrest b
Att 3 - Case patient interview questions.docx
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Questionnaire for Patients who Suffered from Cardiac Arrest but Survived
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
NA
Questionnaire for Patients who Suffered Cardiac Arrest but Survived
Att 3 - Case patient interview questions.docx
NA
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Public Health Monitoring
Privacy Act System of Records
Title:
09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems
FR Citation:
57 FR 62812
Number of Respondents:
4
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
4
0
4
0
0
0
Annual IC Time Burden (Hours)
2
0
2
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.