Primary Care Provider Opt-Out Card

Assessing Problem Areas in Referrals for Chronic Hematologic Malignancies and Developing Interventions to Address Them

OMB: 0920-0836

IC ID: 191092

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Information Collection (IC) Details

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Primary Care Provider Opt-Out Card
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-WORD Att 9_PCP Survey Opt Out Card 092309.doc Yes Yes Fillable Printable

Health Health Care Services

09-20-0136, Epidemiologic Studies and Surveillance of Disease Problems  57 FR 62812

160 0
   
Private Sector Businesses or other for-profits
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 160 0 60 0 0 100
Annual IC Time Burden (Hours) 5 0 2 0 0 3
Annual IC Cost Burden (Dollars) 0 0 -308 0 0 308

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