Consumer/Patient Screener

Evaluation of ARRA Comparative Effectiveness Research Dissemination Contractor Efforts

Documents and Forms

Document Name Document Type
Form Form #2 Consumer/Patient Screener Form and Instruction
Form #2 Consumer or Patient Screener Questionnaire Attachment C -- Consumer or Patient Screener Questionnaire.doc Form and Instruction
Attachment E -- Consumer or Patient Repondent Materials.doc Attachment E -- Consumer or Patient Repondent Materials IC Document

Information Collection (IC) Details

IC Title:	Consumer/Patient 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	Form #2	Consumer or Patient Screener Questionnaire	Attachment C -- Consumer or Patient Screener Questionnaire.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,560	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,560	2,560
Annual IC Time Burden (Hours)	213	213
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment E -- Consumer or Patient Repondent Materials	Attachment E -- Consumer or Patient Repondent Materials.doc	11/30/2011

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.