Information Collection

Practice Managers Form C Shortened Survey Administered on Paper

IC 209872 under ICR 201312-0955-001 · OMB 0955-0015.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0955-0015 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
20475 ID_Form C Shortened Survey Administered.docx	Other-survey

IC Title:

Practice Managers Form C Shortened Survey Administered on Paper

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
Other-survey			20475 ID_Form C Shortened Survey Administered.docx		No	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 118

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	118	118
Annual IC Time Burden (Hours)	20	20
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.