One-Month Patient Follow-up Telephone Call

Pilot Test of an Emergency Department (ED) Discharge Tool

Documents and Forms

Document Name Document Type
Form 2 One-Month Patient Follow-up Telephone Call Form and Instruction
2 One-Month Patient Follow-up Telephone Call Attachment C - One-Month Patient Follow-up Phone Call 2013.12.13.docx Form and Instruction

Information Collection (IC) Details

IC Title:	One-Month Patient Follow-up Telephone Call	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	2	One-Month Patient Follow-up Telephone Call	Attachment C - One-Month Patient Follow-up Phone Call 2013.12.13.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 900	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	900	900
Annual IC Time Burden (Hours)	150	150
Annual IC Cost Burden (Dollars)	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.