Information Collection

Interviews with Practice Manager and Physician Leader

IC 206887 under ICR 201305-0935-001 · OMB 0935-0212.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #4 Interviews with Practice Manager and Physician Leader	Form and Instruction
Form #4 Guide for Interview with Practice Manager Attachment D -- Guide for Interview with Practice Manager.docx	Form and Instruction
Form #4B Guide for Interview with Physician Leader Attachment E -- Guide for Interview with Physician Leader.docx	Form and Instruction
Attachment O -- Information Sheet for Practice Managers.docx Attachment O -- Information Sheet for Practice Managers	IC Document
Attachment P -- Information Sheet for Clinicians.docx Attachment P -- Information Sheet for Clinicians	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	Form #4	Guide for Interview with Practice Manager	Attachment D -- Guide for Interview with Practice Manager.docx		Yes	Yes	Paper Only
Form and Instruction	Form #4B	Guide for Interview with Physician Leader	Attachment E -- Guide for Interview with Physician Leader.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 12

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

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	12	12
Annual IC Time Burden (Hours)	12	12
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment O -- Information Sheet for Practice Managers	Attachment O -- Information Sheet for Practice Managers.docx	05/07/2013
Attachment P -- Information Sheet for Clinicians	Attachment P -- Information Sheet for Clinicians.docx	05/07/2013

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