Information Collection

Data Collection Form for Physicians

IC 184189 under ICR 200803-0925-004 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 Data Collection Form for Physicians	Form
2 Data Collection for Physicians Attach 2_Data Collection Form for Physicians.doc	Form
Attach 1_Letter to doctor final_rev.doc Attach 1_Letter to doctor final_rev	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? Yes

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	2	Data Collection for Physicians	Attach 2_Data Collection Form for Physicians.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	17	17
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attach 1_Letter to doctor final_rev	Attach 1_Letter to doctor final_rev.doc	02/20/2008

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