Information Collection

Health Care Providers

IC 188807 under ICR 200809-0925-003 · OMB 0925-0530.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0530 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Health Care Providers	Form and Instruction
1 survey HCP survey instrument revised 3 24.docx	Form and Instruction
cover memo 0530.doc cover memo 0530	IC Document
gc form 0530.doc gc form 0530	IC Document

IC Title:

Health Care Providers

Agency IC Tracking Number:

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 and Instruction	1	survey	HCP survey instrument revised 3 24.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 400

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 New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	400	0	0	0	0	0
Annual IC Time Burden (Hours)	20	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
cover memo 0530	cover memo 0530.doc	04/08/2009
gc form 0530	gc form 0530.doc	04/08/2009

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