Information Collection

Physicians

IC 196028 under ICR 201102-0925-010 · OMB 0925-0632.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Screener Physicians	Form and Instruction
Form 2 Assessment Physicians	Form and Instruction
1 Screener N44DA-9-2214Attachment3ScreeningTool_March2011.doc	Form and Instruction
2 Assessment N44DA-9-2214-Attachment5AssessmentForms_March2011.doc	Form and Instruction
N44DA-9-2214-Attachment4InitialContact_March2011.doc N44DA-9-2214-Attachment4InitialContact_March2011	IC Document

IC Title:

Physicians

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 and Instruction	1				Yes	Yes	Fillable Fileable
Form and Instruction	2				Yes	Yes	Fillable Fileable

Line of Business: Education

Subfunction: Higher Education

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 80

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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
N44DA-9-2214-Attachment4InitialContact_March2011		04/04/2011

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

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