Crisis Center Data Abstraction Form

Hospital Data Abstraction Form, Evaluation of Emergency Department Crisis Center Follow-up

Documents and Forms

Document Name Document Type
Form Crisis Center Data Crisis Center Data Abstraction Form Form and Instruction
Crisis Center Data Crisis Center Data Abstraction Form Attachment B_Elements for Crisis Center Data Extraction rev.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Crisis Center Data Abstraction Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

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	Crisis Center Data Abstraction Form	Crisis Center Data Abstraction Form	Attachment B_Elements for Crisis Center Data Extraction rev.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

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

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-333	333
Annual IC Time Burden (Hours)	-13	13
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.