Information Collection

Physician/Office Staff

IC 188611 under ICR 200903-0925-003 · OMB 0925-0414.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0414 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
SS_A_Attachment_7-Physician_Questionnaire_Instructions.pdf	Instruction
3 questionaire SS_A_Attachment_6-Physician_Questionnaires.pdf	Form

IC Title:

Physician/Office Staff

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
Instruction			SS_A_Attachment_7-Physician_Questionnaire_Instructions.pdf		Yes	Yes	Paper Only
Form	3	questionaire	SS_A_Attachment_6-Physician_Questionnaires.pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 9

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	9	9
Annual IC Time Burden (Hours)	1	1
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.