Information Collection

Cx3 Study - Follow-up Provider Survey

IC 188623 under ICR 201205-0920-008 · OMB 0920-0814.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Att D2_Follow-up Provider Survey_0209.doc	Other-WORD
Att D2a_ Cover letter -- follow-up provider surveys_0209.doc Att D2a_ Cover letter -- follow-up provider surveys_0209	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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
Other-WORD			Att D2_Follow-up Provider Survey_0209.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

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

FR Citation: 57 FR 252

Number of Respondents: 23

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-46	46
Annual IC Time Burden (Hours)	-23	23
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att D2a_ Cover letter -- follow-up provider surveys_0209	Att D2a_ Cover letter -- follow-up provider surveys_0209.doc	02/23/2009

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