Information Collection

Health Care Providers

IC 184281 under ICR 200803-0925-005 · OMB 0925-0593.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0593 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form C.9.3 Health Care Providers	Form and Instruction
C.9.3 Instruments C.9.3 Healthcare Provider Questionnaire.doc	Form and Instruction
A.2.1 Instruments A.2.1.h Participant Evaluation Questionnaire_Revised.doc	Form and Instruction
A.2.3 Instruments A.2.3.l Blood Draw Data Collection Form_Revised.doc	Form and Instruction

IC Title:

Health Care Providers

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	C.9.3	Instruments	C.9.3 Healthcare Provider Questionnaire.doc	Yes	Yes	Paper Only
Form and Instruction	A.2.1	Instruments	A.2.1.h Participant Evaluation Questionnaire_Revised.doc	Yes	Yes	Paper Only
Form and Instruction	A.2.3	Instruments	A.2.3.l Blood Draw Data Collection Form_Revised.doc	Yes	Yes	Paper Only

Line of Business: General Science and Innovation

Subfunction: Scientific and Technological Research and Innovation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

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	165	165
Annual IC Time Burden (Hours)	8	8
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.