Information Collection

Chiropractic and Pharmacy Loan Repayment Program- Survey of Clinic Users

IC 178405 under ICR 200701-0915-004 · OMB 0915-0306.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Clinic User Survey Chiropractic and Pharmacy Loan Repayment Program- Survey of Clinic Users	Form and Instruction
Clinic User Survey Clinic User Survey- Pharmacist Tab B- Clinic User Survey-Pharmacy.doc	Form and Instruction
Clinic User Survey Clinic User Survey- Chiro Tab B- Clinic User Survey-Chiropractic.doc	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Clinic User Survey- Pharmacist	Clinic User Survey- Pharmacist	Tab B- Clinic User Survey-Pharmacy.doc		No	No	Paper Only
Form and Instruction	Clinic User Survey- Chiro	Clinic User Survey- Chiro	Tab B- Clinic User Survey-Chiropractic.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,000	2,000
Annual IC Time Burden (Hours)	500	500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.