Information Collection

Physicians

IC 192889 under ICR 201301-0925-002 · OMB 0925-0491.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Physician Questionaire Physicians	Form and Instruction
1 Physician Questionaire Attachment 11-Physician Questionnaire (PHQ) Form.doc	Form and Instruction

IC Title:

Physicians

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 and Instruction	1	Physician Questionaire	Attachment 11-Physician Questionnaire (PHQ) Form.doc		No	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 200

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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