Information Collection

Clinician Survey

IC 200334 under ICR 201112-0935-001 · OMB 0935-0191.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #1 Clinician Survey	Form and Instruction
Form #1 Clinician Questionnaire Attachment A -- Clinician Questionnaire.docx	Form and Instruction
Attachment B -- Clinician Survey Respondent Materials.doc Attachment B -- Clinician Survey Respondent Materials	IC Document

IC Title:

Clinician 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	Form #1	Clinician Questionnaire	Attachment A -- Clinician Questionnaire.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,852

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

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	3,852	3,852
Annual IC Time Burden (Hours)	1,284	1,284
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment B -- Clinician Survey Respondent Materials	Attachment B -- Clinician Survey Respondent Materials.doc	11/30/2011

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