Patient Interview Guide

The Re-engineered Visit for Primary Care (AHRQ REV)

Documents and Forms

Document Name Document Type
Form 6 Patient Interview Guide Form and Instruction
6 Attachment L: Patient Interview Guide Attachment L Patient Interview Guide JSI_AHRQ.REV.11.2016.fine.version.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Patient Interview Guide	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	6	Attachment L: Patient Interview Guide	Attachment L Patient Interview Guide JSI_AHRQ.REV.11.2016.fine.version.docx		No		Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 90	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	90	90
Annual IC Time Burden (Hours)	45	45
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.