Information Collection

Public Health Service Site Selection Questionnaire For Physicians And Dentists

IC 110026 under ICR 197703-0915-001 · OMB 0915-0002.

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Information Collection (IC) Details

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IC Title:	PUBLIC HEALTH SERVICE SITE SELECTION QUESTIONNAIRE FOR PHYSICIANS AND DENTISTS	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

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	HSABCHS 0612				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	6,000	4,275	1,725
Annual IC Time Burden (Hours)	1,500	1,120	380
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.