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

SelectMD 2.0 Clinician Choice Experiment

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Attachment C – 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:

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 %

	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

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.