Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Community Health Center Induction Interview Form New 104 35 0 Form unnumbered Community Health Center Induction Interview
Electronic Medical Record/Electronic Health Record Mail Survey Form New 1143 381 0 Form unnumbered EMR/EHR Mail Survey form
Lab Pretest Patient Record Form Modified 240 36 0 Form unnumbered Att. I Lab Pretest Patient Record form
Lab Values Pretest Induction form New 23 11 0 Form unnumbered Lab Values Pretest Induction form
Office-Based Physicians eligible/Cervical Cancer Screening Supplement Modified 464 116 0 Form unnumbered Cervical Cancer Screening Supplement (Att. U)
Office-Based Physicians eligible/Pulling and Re-filing Patient Record Form Modified 19500 325 0 Instruction
Office-Based Physicians ineligible/Physician Induction Interview Removed 0 0 0 Instruction
Office-based Physicians eligible/Patient Record Form Modified 22140 3321 0 Form unnumbered Patient Record Form
Office-based physicians /Physician Induction Interview Modified 3657 1707 0 Form unnumbered Physician Induction Interview (Line 1)
Total burden requested under this ICR: 47271 5932 0  
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