Clinician Survey

Evaluation of ARRA Comparative Effectiveness Research Dissemination Contractor Efforts

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.