Information Collection

Provider Questionnaire

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

Documents and Forms

Documents and forms in this information collection
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

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.