Information Collection

Providers - e-RX Deployment

IC 210541 under ICR 201301-0917-001 · OMB 0917-0036.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0917-0036 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form OMB No. 0917-0036- Providers - e-RX Deployment	Form and Instruction
OMB No. 0917-0036- OMB No. 0917-0036-35, Providers - eRX Deployment Providers - eRX Deployment.pdf	Form and Instruction
OMB No. 0917-0036-35, e-Prescribing End User Survey.doc OMB No. 0917-0036-35, Mini-Supporting Statement for e-Prescribing End User Survey	IC Document

IC Title:

Providers - e-RX Deployment

Agency IC Tracking Number:

IC Status: New

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 and Instruction	OMB No. 0917-0036-35	OMB No. 0917-0036-35, Providers - eRX Deployment	Providers - eRX Deployment.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 300

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	300	300
Annual IC Time Burden (Hours)	25	25
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
OMB No. 0917-0036-35, Mini-Supporting Statement for e-Prescribing End User Survey	OMB No. 0917-0036-35, e-Prescribing End User Survey.doc	02/25/2014

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