Information Collection

Survey of Clinicians and Office Staff

IC 206889 under ICR 201305-0935-001 · OMB 0935-0212.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #6 Survey of Clinicians and Office Staff	Form and Instruction
Form #6 Clinician and Office Staff Survey Attachment I -- Clinician and Office Staff Survey.docx	Form and Instruction
Attachment H -- Clinician and Office Staff Survey Invitation.docx Attachment H -- Clinician and Office Staff Survey Invitation	IC Document
Attachment H -- Clinician and Office Staff Survey Invitation.docx Attachment H -- Clinician and Office Staff Survey Invitation	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 #6	Clinician and Office Staff Survey	Attachment I -- Clinician and Office Staff Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 138

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	138	138
Annual IC Time Burden (Hours)	35	35
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment H -- Clinician and Office Staff Survey Invitation	Attachment H -- Clinician and Office Staff Survey Invitation.docx	05/07/2013
Attachment H -- Clinician and Office Staff Survey Invitation	Attachment H -- Clinician and Office Staff Survey Invitation.docx	05/07/2013

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