Information Collection

Non Participant Components

IC 182193 under ICR 201110-0925-002 · OMB 0925-0584.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0584 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Non Participant Components	Form and Instruction
1 Questionaire Physician Qx_English only.doc	Form and Instruction
2 Informant Interview Informant interview_English.doc	Form and Instruction

IC Title:

Non Participant Components

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	Questionaire	Physician Qx_English only.doc		Yes	Yes	Fillable Fileable
Form and Instruction	2	Informant Interview	Informant interview_English.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,284

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	Previously Approved
Annual Number of Responses for this IC	1,284	-4,049	5,333
Annual IC Time Burden (Hours)	642	-2,025	2,667
Annual IC Cost Burden (Dollars)	0	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.