Information Collection

MHI-LV1: Physician/administrator

IC 213676 under ICR 201410-0935-003 · OMB 0935-0227.

Documents and Forms

Document Name Document Type
Form 2 MHI-LV1: Physician/administrator Form and Instruction
2 MHI-LV1: Physician/administrator Appendix_B_the MHI tool_UPD2.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	MHI-LV1: Physician/administrator	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	MHI-LV1: Physician/administrator	Appendix_B_the MHI tool_UPD2.pdf		No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 30	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	70	70
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.