Information Collection

Cx3 Study - Baseline Provider Survey

IC 188622 under ICR 200903-0920-010 · OMB 0920-0814.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0814 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att D1_Baseline Provider Survey_0209.doc	Other-WORD
Att D1a_Cover letter -- baseline provider survey_0209.doc Att D1a_Cover letter -- baseline provider survey_0209	IC Document

IC Title:

Cx3 Study - Baseline Provider Survey

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-WORD			Att D1_Baseline Provider Survey_0209.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 252

Number of Respondents: 23

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	23	23
Annual IC Time Burden (Hours)	12	12
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att D1a_Cover letter -- baseline provider survey_0209	Att D1a_Cover letter -- baseline provider survey_0209.doc	02/23/2009

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