Information Collection

Non Participant Components

IC 182193 under ICR 201406-0925-002 · OMB 0925-0584.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Questionaire Non Participant Components	Form and Instruction
Form 2 Informant Interview Non Participant Components	Form and Instruction
1 Questionaire Physician Qx_English only.doc	Form and Instruction
2 Informant Interview Informant interview_English.doc	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

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				Yes	Yes	Fillable Fileable
Form and Instruction	2				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,284

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-1,284	1,284
Annual IC Time Burden (Hours)	-642	642
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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].