Information Collection

Health Care Providers

IC 192912 under ICR 201005-0925-007 · OMB 0925-0621.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0621 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 Health Care Providers	Form
2 Screening Instrument Attachment 3 4_12_10.docx	Form
1 Assessment Instrument Attachment 5 4_12_10.docx	Form
Attachment 4 4_12_10.docx Initial Contact email/Participant information	IC Document

IC Title:

Health Care Providers

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	2	Screening Instrument	Attachment 3 4_12_10.docx		Yes	Yes	Paper Only
Form	1	Assessment Instrument	Attachment 5 4_12_10.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 80

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

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	240	240
Annual IC Time Burden (Hours)	180	180
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Initial Contact email/Participant information	Attachment 4 4_12_10.docx	04/30/2010

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