Information Collection

Interview with Medical Care Providers

IC 185915 under ICR 200807-0920-005 · OMB 0920-0797.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att 9A. Medical Providers Interview Guide.doc	Other-Interview Guide
Att 9B. Consent Form for Medical Providers Interview.doc Attachment 9B - consent form	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
Other-Interview Guide					No	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 27

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	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	27	27
Annual IC Time Burden (Hours)	27	27
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 9B - consent form		07/14/2008

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

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