Prescreening Questionnaire for Clinicians and Healthcare Professionals

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

Documents and Forms

Document Name Document Type
Form B1 Prescreening Questionnaire for Clinicians and Healthcare Professionals Form
B1 Prescreening Questionnaire for Clinicians and Healthcare Attachment B1. Final Prescreening Questionnaire-Clinicians and Healthcare Professionals .docx Form

Information Collection (IC) Details

IC Title:	Prescreening Questionnaire for Clinicians and Healthcare Professionals	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	B1	Prescreening Questionnaire for Clinicians and Healthcare Professionals	Attachment B1. Final Prescreening Questionnaire-Clinicians and Healthcare Professionals .docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 750	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	750	750
Annual IC Time Burden (Hours)	63	63
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.