Primary Care provider Interview Protocol

Frontier Community Healthcare Network Coordination Grant

Documents and Forms

Document Name Document Type
Form 3 Primary Care provider Interview Protocol Form and Instruction
3 Primary Care Provider Interview Protocol PrimaryCareProviderInterviewGuide_OMBClearancePackage_09242013.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Primary Care provider Interview Protocol	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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	3	Primary Care Provider Interview Protocol	PrimaryCareProviderInterviewGuide_OMBClearancePackage_09242013.docx		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 22	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	22	22
Annual IC Time Burden (Hours)	11	11
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.