OMB
.report
Search
Quarterly Patient Information Form
Integrating Community Pharmacists and Clinical Sites for Patient-Centered HIV Care
OMB: 0920-1019
IC ID: 210979
OMB.report
HHS/CDC
OMB 0920-1019
ICR 201602-0920-007
IC 210979
( )
Documents and Forms
Document Name
Document Type
Quarterly Patient Information Form
Form
Quarterly Patient Information
Att 7a_Quarterly Patient Info Form.docx
Form
Quarterly Patient Information - screenshots
Attachment 7c_Screenshots for Quarterly Patient Info forms.pdf
Form
Att 7b_Quarterly Patient Info Form Instructions.docx
Quarterly Patient Information Form Instructions
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Quarterly Patient Information Form
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
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
none
Quarterly Patient Information
Att 7a_Quarterly Patient Info Form.docx
Yes
Yes
Fillable Fileable
Form
none
Quarterly Patient Information - screenshots
Attachment 7c_Screenshots for Quarterly Patient Info forms.pdf
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:
State, Local, and Tribal Governments
Percentage of Respondents Reporting Electronically:
100 %
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
4,000
0
0
0
0
4,000
Annual IC Time Burden (Hours)
2,000
0
0
0
0
2,000
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Quarterly Patient Information Form Instructions
Att 7b_Quarterly Patient Info Form Instructions.docx
02/17/2016
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.