Information Collection

Pediatrician and Family Physicians Survey

IC 208374 under ICR 201308-0935-002 · OMB 0935-0215.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #1 Pediatrician and Family Physician Survey Pediatrician and Family Physicians Survey	Form and Instruction
Form #1 Pediatrician and Family Physician Survey Attachment B - Pediatrician and Family Physician Survey.docx	Form and Instruction
Attachment D - CHIPRA_reminder postcard.docx Attachment D - CHIPRA_reminder postcard	IC Document
Attachment C -CHIPRA physician survey advance and cover letters.docx Attachment C -CHIPRA physician survey advance and cover letters	IC Document
Attachment E- CHIPRA physician survey reminder letter.docx Attachment E- CHIPRA physician survey reminder letter	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 #1				Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,200

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	1,200	1,200
Annual IC Time Burden (Hours)	300	300
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment D - CHIPRA_reminder postcard		08/22/2013
Attachment C -CHIPRA physician survey advance and cover letters		08/22/2013
Attachment E- CHIPRA physician survey reminder letter		08/22/2013

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

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