Health Care Provider Verification Form

Registry of Unexplained Fatiguing Illnesses and Chronic Fatigue Syndrome (CFS): A Pilot Study

Documents and Forms

Document Name Document Type
Form No number Health Care Provider Verification Form Form and Instruction
No number Attachment 5 - Healthcare Provider Verification Appendix 5a.2.Healthcare Provider Verification form.doc Form and Instruction
Attachment 5a.1.Provider recruitment letter.doc Attachment 5a IC Document
Attachment 5a.3. Frequently Asked Questions by Healthcare Providers .doc Attachment 5a IC Document
Attachment 5b Provider website Frequently Asked Questions.doc Attachment 5b Provider website Frequently Asked Questions IC Document

Information Collection (IC) Details

IC Title:	Health Care Provider Verification Form	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 and Instruction	No number	Attachment 5 - Healthcare Provider Verification	Appendix 5a.2.Healthcare Provider Verification form.doc		Yes	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: Epidemiologic Studies and Surveillance of Disease Problems	FR Citation: 57 FR 62812

Number of Respondents: 583	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	583	583
Annual IC Time Burden (Hours)	165	165
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment 5a	Attachment 5a.1.Provider recruitment letter.doc	12/19/2007
Attachment 5a	Attachment 5a.3. Frequently Asked Questions by Healthcare Providers .doc	12/19/2007
Attachment 5b Provider website Frequently Asked Questions	Attachment 5b Provider website Frequently Asked Questions.doc	12/19/2007

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