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Patient Interviews
Patient-Reported Health Information Technology and Workflow
OMB: 0935-0212
IC ID: 206890
OMB.report
HHS/AHRQ
OMB 0935-0212
ICR 201305-0935-001
IC 206890
( )
Documents and Forms
Document Name
Document Type
Form Form #7
Patient Interviews
Form and Instruction
Form #7 Patient Interview Guide
Attachment J -- Patient Interivew Guide.docx
Form and Instruction
Attachment R -- Information Sheet for Patient Interviews and Observations.docx
Attachment R -- Information Sheet for Patient Interviews and Observations
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Patient Interviews
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 #7
Patient Interview Guide
Attachment J -- Patient Interivew Guide.docx
Yes
Yes
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Public Health Monitoring
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
36
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
36
0
36
0
0
0
Annual IC Time Burden (Hours)
18
0
18
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Attachment R -- Information Sheet for Patient Interviews and Observations
Attachment R -- Information Sheet for Patient Interviews and Observations.docx
05/07/2013
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.