Information Collection

Referral/Consent to Contact Form - Provider

IC 183858 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 Referral/Consent to Contact Form - Provider	Form
No number Referral/Consent to Contact Form - Provider Attachment 7 Referral- Consent to Contact Form for Providers.doc	Form

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	No number	Referral/Consent to Contact Form - Provider	Attachment 7 Referral- Consent to Contact Form for Providers.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: 373

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	746	746
Annual IC Time Burden (Hours)	99	99
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.