Pre-Choice Test Questionnaire

SelectMD 2.0 Clinician Choice Experiment

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Pre-Choice Test Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	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 %

	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

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.