Information Collection

Practitioner Survey

IC 195858 under ICR 201012-0930-003 · OMB 0930-0321.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Practitioner Surve Practitioner Survey	Form and Instruction
Practitioner Surve Practitioner Survey Attachment 2 Practitioner Survey.doc	Form and Instruction
Attachment 3 Network Security at RTI.doc Network Security	IC Document
Attachment 4 Privacy Pledge.doc Privacy Pledge	IC Document
Attachment 5 Practitioner Informed Consent.doc Practitioner Informed Consent	IC Document
Attachment 6 Table Shell Descriptive Results.doc Table Shell	IC Document
Attachment 1 Evaluation Questions 2011-03-21 (2).docx Evaluation Questions	IC Document

IC Title:

Practitioner Survey

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 and Instruction	Practitioner Survey	Practitioner Survey	Attachment 2 Practitioner Survey.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,075

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	1,075	1,075
Annual IC Time Burden (Hours)	323	323
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Network Security	Attachment 3 Network Security at RTI.doc	12/17/2010
Privacy Pledge	Attachment 4 Privacy Pledge.doc	12/17/2010
Practitioner Informed Consent	Attachment 5 Practitioner Informed Consent.doc	12/17/2010
Table Shell	Attachment 6 Table Shell Descriptive Results.doc	12/17/2010
Evaluation Questions	Attachment 1 Evaluation Questions 2011-03-21 (2).docx	03/22/2011

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