Information Collection

Online Survey: Pediatric Palliative Care Provider Resources

IC 227193 under ICR 201503-0925-004 · OMB 0925-0653.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0653 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Online Survey: Pediatric Palliative Care Provider Resources	Form
1 Appendix A Provider Survey Appendix A Provider Survey (2).docx	Form
Fast Track Template_Provider Resources Survey 6.13.17.doc Fast Track Template Provider Resources	IC Document
Appendix B Outreach Language_Provider Resources_6.01.17 (1).docx Appendix B Outreach Language Provider Resources	IC Document

IC Title:

Online Survey: Pediatric Palliative Care Provider Resources

Agency IC Tracking Number:

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	1	Appendix A Provider Survey	Appendix A Provider Survey (2).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40

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	40	40
Annual IC Time Burden (Hours)	3	3
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Fast Track Template Provider Resources	Fast Track Template_Provider Resources Survey 6.13.17.doc	06/15/2017
Appendix B Outreach Language Provider Resources	Appendix B Outreach Language_Provider Resources_6.01.17 (1).docx	06/15/2017

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