Information Collection

Provider-Based Sampling Frame Questionnaire (PBS)

IC 202207 under ICR 201211-0925-001 · OMB 0925-0593.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0593 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2.3 Provider-Based Sampling Frame Questionnaire (PBS)	Form and Instruction
2.3 Survey Provider Based Sampling Frame Questionnaire Worcester Co 20120413.docx	Form and Instruction
2.1 Survey Provider Based Sampling Frame Questionnaire Harris Co 20120413.docx	Form and Instruction
2.2 Survey Provider Based Sampling Frame Questionnaire Jefferson Co 20120413.docx	Form and Instruction
2.4 Survey PBS Recruitment Response Form 20120413.docx	Form and Instruction
Advance Letter to Providers.docx Advance Letter to Providers	IC Document
Exemplar Letter to Accompany Questionnaire.doc Exemplar Letter to Accompany Questionnaire	IC Document
Provider Based Sampling Advance Letter to Office Manager.docx Advance Letter to Office Manager	IC Document
Provider Based Sampling Brochure.docx PBS Brochure	IC Document
Provider Based Sampling Provider List Revision Letter.doc Provider List Revision Letter	IC Document
Attach A17. PFQ Refusal Letter for Providers_final.docx Attach A17. PFQ Refusal Letter for Providers_final	IC Document

IC Title:

Provider-Based Sampling Frame Questionnaire (PBS)

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	2.3	Survey	Provider Based Sampling Frame Questionnaire Worcester Co 20120413.docx	Yes	Yes	Fillable Printable
Form and Instruction	2.1	Survey	Provider Based Sampling Frame Questionnaire Harris Co 20120413.docx	Yes	Yes	Fillable Printable
Form and Instruction	2.2	Survey	Provider Based Sampling Frame Questionnaire Jefferson Co 20120413.docx	Yes	Yes	Fillable Printable
Form and Instruction	2.4	Survey	PBS Recruitment Response Form 20120413.docx	Yes	Yes	Paper Only

Line of Business: General Science and Innovation

Subfunction: Scientific and Technological Research and Innovation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	21	21
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Advance Letter to Providers	Advance Letter to Providers.docx	04/16/2012
Exemplar Letter to Accompany Questionnaire	Exemplar Letter to Accompany Questionnaire.doc	04/16/2012
Advance Letter to Office Manager	Provider Based Sampling Advance Letter to Office Manager.docx	04/16/2012
PBS Brochure	Provider Based Sampling Brochure.docx	04/16/2012
Provider List Revision Letter	Provider Based Sampling Provider List Revision Letter.doc	04/16/2012
Attach A17. PFQ Refusal Letter for Providers_final	Attach A17. PFQ Refusal Letter for Providers_final.docx	03/07/2013

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