Physicians (Pediatric Palliative Care Campaign Pilot Survey)

Pediatric Palliative Care Campaign Pilot Survey (NINR)

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Physicians (Pediatric Palliative Care Campaign Pilot Survey)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection 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 %

	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

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.