Information Collection

Follow-up Provider Survey

IC 188621 under ICR 201205-0920-008 · OMB 0920-0814.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Follow-up Provider Survey Follow-up Provider Survey	Form
Follow-up Provider Survey C1 Follow-up Provider Survey 4 27 2012.doc	Form
C1a Cover Letter for Follow-up Provider Survey.docx Provider Cover Letter	IC Document

IC Title:

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	none				Yes	No	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: 09-20-0136 Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 252

Number of Respondents: 70

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

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	70	4	66
Annual IC Time Burden (Hours)	35	-31	66
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Provider Cover Letter		05/17/2012

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

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