Information Collection

Health Care Provider Knowledge, Attitudes and Beliefs Questionnaire - Pre-Intervention

IC 183856 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 Knowledge, Attitudes and Beliefs Questionnaire - Pre-Intervention	Form and Instruction
No number Provider Questionnaire - Pre-intervention Attachment 6b Provider Questionnaire (Knowledge Attitues Beliefs) Pre-intervention.doc	Form and Instruction
Attachment 6a Non-physician referral instructions.doc Attachment 6a Non-physician referral instructions	IC Document
Attachment 6a Physician Referral Instructions.doc Attachment 6a Physician Referral Instructions	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	Provider Questionnaire - Pre-intervention	Attachment 6b Provider Questionnaire (Knowledge Attitues Beliefs) Pre-intervention.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: 466

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	466	466
Annual IC Time Burden (Hours)	62	62
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 6a Non-physician referral instructions	Attachment 6a Non-physician referral instructions.doc	12/19/2007
Attachment 6a Physician Referral Instructions	Attachment 6a Physician Referral Instructions.doc	12/19/2007

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