Quarterly Patient Information Form

Integrating Community Pharmacists and Clinical Sites for Patient-Centered HIV Care

OMB: 0920-1019

IC ID: 210979

Information Collection (IC) Details

View Information Collection (IC)

Quarterly Patient Information Form
 
No Modified
 
Voluntary
 

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

Health Health Care Services

 

10 0
   
State, Local, and Tribal Governments
 
   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

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.

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