Information Collection

Chiropractic and Pharmacy Loan Repayment- Survey of Clinic Medical Directors

IC 178406 under ICR 200701-0915-004 · OMB 0915-0306.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Survey of Clinic M Chiropractic and Pharmacy Loan Repayment- Survey of Clinic Medical Directors	Form
Survey of Clinic M Survey of Clinic Medical Directors- Pharm Tab C- MedDirs Survey-Pharm.doc	Form
Survey of Clinic M Survey of Clinic Medical Directors- Chiro Tab C- Medical Directors Survey-Chiropractic.doc	Form
Tab C- Cover Letter Demonstration clinics.doc Cover Letter to Medical Directors- Demo Clinics	IC Document
Tab C- Cover Letter Comparison Clinics.doc Cover Letter to Medical Directors- Comparison Clinics	IC Document

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	Survey of Clinic Medical Directors- Pharm	Survey of Clinic Medical Directors- Pharm	Tab C- MedDirs Survey-Pharm.doc		No	No	Paper Only
Form	Survey of Clinic Medical Directors - Chiro	Survey of Clinic Medical Directors- Chiro	Tab C- Medical Directors 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: 60

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	60	60
Annual IC Time Burden (Hours)	30	30
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Cover Letter to Medical Directors- Demo Clinics	Tab C- Cover Letter Demonstration clinics.doc	08/02/2006
Cover Letter to Medical Directors- Comparison Clinics	Tab C- Cover Letter Comparison Clinics.doc	08/02/2006

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