Prescreening Questionnaire for Patients and Care Partners

ACCESS, EXCHANGE, AND USE OF SOCIAL DETERMINANTS OF HEALTH DATA IN CLINICAL NOTES

Documents and Forms

Document Name Document Type
Form B2 Prescreening Questionnaire for Patients and Care Partners Form
B2 Patients and Care Partners Prescreening Questionnaire Attachment B2. Final Prescreening Questionnaire-Patients and Care Partners (English).docx Form

Information Collection (IC) Details

IC Title:	Prescreening Questionnaire for Patients and Care Partners	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	B2	Patients and Care Partners Prescreening Questionnaire	Attachment B2. Final Prescreening Questionnaire-Patients and Care Partners (English).docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 675	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	675	675
Annual IC Time Burden (Hours)	56	56
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.