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Screener
Palliative Care: Conversations Matter Phase Two Evaluation (NINR)
OMB: 0925-0683
IC ID: 223525
OMB.report
HHS/NIH
OMB 0925-0683
ICR 201609-0925-002
IC 223525
( )
Documents and Forms
Document Name
Document Type
Form 1
Screener
Form and Instruction
1 Survey screenshot
Attachment 2 - Survey Screenshots.pdf
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Screener
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
1
Survey screenshot
Attachment 2 - Survey Screenshots.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:
10,000
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
100 %
Requested
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
10,000
0
10,000
0
0
0
Annual IC Time Burden (Hours)
333
0
333
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.