Information Collection

Physician Permission to Contact Potential Survey Respondents

IC 188830 under ICR 200904-0920-010 · OMB 0920-0815.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Physician Permission to Contact Potential Survey Respondents	Form
Permission to Contact Potential Participants Attachment D_LIST OF POTENTIAL STUDY PARTICIPANTS.doc	Form
Attachment D2_COVER LETTER FOR PHYSICIANS.doc Cover Letter to Physicians	IC Document

IC Title:

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
Form	none	Permission to Contact Potential Participants	Attachment D_LIST OF POTENTIAL STUDY PARTICIPANTS.doc		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

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

FR Citation: 57 FR 62812

Number of Respondents: 1,950

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,950	1,950
Annual IC Time Burden (Hours)	423	423
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Cover Letter to Physicians	Attachment D2_COVER LETTER FOR PHYSICIANS.doc	04/01/2009

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