Information Collection

Physicians (Pediatric Palliative Care Campaign Pilot Survey)

IC 206301 under ICR 201303-0925-005 · OMB 0925-0672.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Physicians (Pediatric Palliative Care Campaign Pilot Survey)	Form and Instruction
1 Pediatric Palliative Care Campaign Pilot Survey Attachment 2_Survey Screenshots.pdf	Form and Instruction
Attachment 1_Survey Word Version.doc Attachment 1_Survey Word Version	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

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	1	Pediatric Palliative Care Campaign Pilot Survey	Attachment 2_Survey Screenshots.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 25

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	25	25
Annual IC Time Burden (Hours)	13	13
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment 1_Survey Word Version	Attachment 1_Survey Word Version.doc	03/13/2013

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