Information Collection

Survey of Patients' Perceptions of the Impact of Third Party Billing on Clinical Research Participation

IC 207221 under ICR 201401-0925-006 · OMB 0925-0458.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Survey of Patients' Perceptions of the Impact of Third Party Billing on Clinical Research Participation	Form and Instruction
1 Third Party Billing Survey 3rd Party Survey Questions OMB Submission.docx	Form and Instruction
Mini Supporting Statement CC Third Party Billing.docx Mini Supporting Statement CC Third Party Billing	IC Document

IC Title:

Agency IC Tracking Number:

IC Status: Unchanged

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	1	Third Party Billing Survey	3rd Party Survey Questions OMB Submission.docx		No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,000	4,000
Annual IC Time Burden (Hours)	1,000	1,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Mini Supporting Statement CC Third Party Billing	Mini Supporting Statement CC Third Party Billing.docx	06/05/2013

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