OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Pre-Choice Test Questionnaire

IC 211641 under ICR 201405-0935-007 · OMB 0935-0219.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Pre-Choice Test Questionnaire
 
No New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 1 Pre-Choice Questionnaire Attachment D-1_SelectMD 2.0 Pre-Choice Questionnaire.docx Yes Yes Fillable Fileable

Health Health Care Services

Pre-Choice Test Questionnaire  79 FR 4718

1,575 0
   
Individuals or Households
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 1,575 0 1,575 0 0 0
Annual IC Time Burden (Hours) 263 0 263 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Attachment B – SelectMD 2.0 Clinician Choice Experiment Invitation Attachment B_SelectMD 2.0 Invitation.doc 05/16/2014
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.