Information Collection

(EGAPP) - Health Care Providers (att D1)

IC 179073 under ICR 200902-0920-008 · OMB 0920-0751.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form No number (EGAPP) - Health Care Providers (att D1)	Form and Instruction
No number Healthcare provider survey Healthcare Provider Survey Revised 2-6-09.doc	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

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 and Instruction	No number	Healthcare provider survey	Healthcare Provider Survey Revised 2-6-09.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,740

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 95 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,740	0	1,740
Annual IC Time Burden (Hours)	232	-58	290
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.