Information Collection

FORM A_Healthcare Providers (Physicians, Physician Assistants....

IC 198297 under ICR 201106-0990-002 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
0990-ProviderServiceForm_A__Pilot_Practices.docx	Other-Survey
0990-Providers Services Form_A_Info_Collection_for_Gutcheck_Pilot_Practices.docx	Other-survey

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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
Other-Survey			0990-ProviderServiceForm_A__Pilot_Practices.docx		Yes	Yes	Fillable Printable
Other-survey			0990-Providers Services Form_A_Info_Collection_for_Gutcheck_Pilot_Practices.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	20	20
Annual IC Time Burden (Hours)	80	80
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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