Information Collection

Provider Questionnaire

IC 194326 under ICR 201008-0920-011 · OMB 0920-0875.

Documents and Forms

Document Name Document Type
Provider Questionnaire Form
Provider Questionnaire Attachment G Provider Questionnaire.doc Form
Attachment E Provider Invitation Letter.doc Provider invitation letter IC Document
Attachment I-2 Provider Phone Follow-up Prompt & Questionnaire.doc Provider Phone Follow-up IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Provider Questionnaire	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
Form	None	Provider Questionnaire	Attachment G Provider Questionnaire.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 180	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	180	180
Annual IC Time Burden (Hours)	66	66
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Provider invitation letter	Attachment E Provider Invitation Letter.doc	08/04/2010
Provider Phone Follow-up	Attachment I-2 Provider Phone Follow-up Prompt & Questionnaire.doc	08/04/2010

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