Information Collection

2. Selected Survey (one of 5)

IC 7161 under ICR 200803-0920-003 · OMB 0920-0692.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 2. Selected Survey (one of 5)	Form
1 Pediatricians Appendix_C_pediatricians.doc	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? Yes

IC Status: Modified

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	1	Pediatricians	Appendix_C_pediatricians.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 900

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	900	-3,100	4,000
Annual IC Time Burden (Hours)	375	-1,625	2,000
Annual IC Cost Burden (Dollars)	0	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.