Information Collection

Attachment C – SelectMD 2.0 Clinician Choice Experiment Overview & Sample Wireframes

IC 211659 under ICR 201405-0935-007 · OMB 0935-0219.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 Attachment C – SelectMD 2.0 Clinician Choice Experiment Overview & Sample Wireframes	Form and Instruction
2 SelectMD 2.0 Clinician Choice Experiment Overview & Samp Attachment C_SelectMD 2.0 Clinician Choice Experiment Overview and Sample Wireframes.doc	Form and Instruction

IC Title:

Attachment C â SelectMD 2.0 Clinician Choice Experiment Overview & Sample Wireframes

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	2	SelectMD 2.0 Clinician Choice Experiment Overview & Sample Wireframes	Attachment C_SelectMD 2.0 Clinician Choice Experiment Overview and Sample Wireframes.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: SelectMD 2.0 Clinician Choice Experiment Overview & Sample Wireframes

FR Citation: 79 FR 4721

Number of Respondents: 1,500

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	1,500	1,500
Annual IC Time Burden (Hours)	250	250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.