Information Collection

Pre-Choice Test Questionnaire

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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Pre-Choice Test Questionnaire	Form and Instruction
1 Pre-Choice Questionnaire Attachment D-1_SelectMD 2.0 Pre-Choice Questionnaire.docx	Form and Instruction
Attachment B_SelectMD 2.0 Invitation.doc Attachment B – SelectMD 2.0 Clinician Choice Experiment Invitation	IC Document

IC Title:

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
Form and Instruction	1	Pre-Choice Questionnaire	Attachment D-1_SelectMD 2.0 Pre-Choice Questionnaire.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Pre-Choice Test Questionnaire

FR Citation: 79 FR 4718

Number of Respondents: 1,575

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,575	1,575
Annual IC Time Burden (Hours)	263	263
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment B â 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.