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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
SS_A_Attachment_7-Physician_Questionnaire_Instructions.pdf Instruction
3 questionaire SS_A_Attachment_6-Physician_Questionnaires.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.