Information Collection

Health Care Providers

IC 192912 under ICR 201011-0925-005 · OMB 0925-0621.

Documents and Forms

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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	Previously Approved
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.