Information Collection

Provider Interview

IC 208789 under ICR 201309-0930-002 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Health Care Profes Provider Interview	Form and Instruction
Health Care Profes Health Care Professional Interview Guide Attachment C - Health Care Professional Interview Guide.docx	Form and Instruction
Attachment E - Invitation Letter for Health Care Provider Interviews.docx Invitation Letter	IC Document

IC Title:

Provider Interview

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	Health Care Professional Interview Guide	Health Care Professional Interview Guide	Attachment C - Health Care Professional Interview Guide.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 42

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	42	42
Annual IC Time Burden (Hours)	32	32
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Invitation Letter	Attachment E - Invitation Letter for Health Care Provider Interviews.docx	09/23/2013

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