Form #1 Form #1 Clinician Group Submission System Registration Form

Attachment A: Clinician and Group Data Submission System Registration Form

C

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

AHPS Clinician and Group Data Submission Registration Form

Registration Step 1: Provide Contact Information

Registration Step 2: Create Username, Password and Security Question

Public reporting burden for this collection of information is estimated to average 6 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

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