Information Collection

Appendix A: CCQM-PC Survey

IC 213632 under ICR 201410-0935-003 · OMB 0935-0227.

Documents and Forms

Document Name Document Type
Form 1 Appendix A: CCQM-PC Survey Form and Instruction
1 CCQM-PC Appendix_A_the CCQM-PC survey_UPD2.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Appendix A: CCQM-PC Survey	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	CCQM-PC	Appendix_A_the CCQM-PC survey_UPD2.pdf		No		Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,500	4,500
Annual IC Time Burden (Hours)	1,875	1,875
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.