Information Collection

Health Care Provider Verification Form

IC 183855 under ICR 200802-0920-009 · OMB 0920-0788.

Documents and Forms

Documents and forms in this information collection
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

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.