Information Collection

Provider Survey (English Only)

IC 209259 under ICR 201311-0920-005 · OMB 0920-1002.

Documents and Forms

Document Name Document Type
Provider Survey (English Only) Form and Instruction
Appendix 12: Provider Survey (English Only) App 12 Provider Survey.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Provider Survey (English Only)	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	None	Appendix 12: Provider Survey (English Only)	App 12 Provider Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 120	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	480	480
Annual IC Time Burden (Hours)	80	80
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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